Neurosurgery Coding Alert

Question: The physician performed a left temporoparietal craniotomy with an open brain tumor biopsy. I'm thinking that this would be coded as unlisted but the doctor says it's 61304 (Craniectomy or craniotomy, exploratory; supratentorial). What should I report?

Arizona Subscriber

Answer: Although this is not an infrequent scenario, you have identified that the coding options are not clear. While you may consider reporting 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) and append modifier 52 (Reduced services), several years ago both CMS and CPT stressed the importance of reporting a code only if the intrinsic elements of the code were actually performed. Since a craniotomy was performed followed by biopsy rather than excision (partial or complete) of the brain tumor, appending the -52 reduced services modifier alerts the carrier that the procedure performed was less extensive than what the code typically reflects. This is a more accurate choice compared to an unlisted code or exploratory craniotomy code.