Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon inserted an implantable cranial pump under the skin to administer pain medication directly into the cerebrospinal fluid (CSF). The medication is delivered via tunneled catheter, and the patient has a diagnosis of “neoplasm, infratent/uncertain behavior.” How should I report this encounter, and what’s a neoplasm of uncertain behavior?

Arkansas Subscriber

Answer: For this encounter, you’ll report 61215 (Insertion of subcutaneous reservoir, pump or continuous infusion system for connection to ventricular catheter) for the pump insertion with D43.1 (Neoplasm of uncertain behavior of brain, infratentorial) appended to represent the patient’s neoplasm.

Uncertain behavior: A neoplasm of uncertain behavior could be either malignant or benign, but it cannot be determined at the time of the service. These neoplasms often require monitoring to see whether the tumor will become malignant or remain localized and benign; hence the “uncertain” diagnosis.