Question: How should I code for neuroendoscopic biopsy? In the first case, our surgeon performed an endoscopic biopsy for tumor; then he performed an endoscopic biopsy for another patient's pineal cyst. Must I report an "unlisted" procedure code?
Arizona Subscriber
Answer: CPT doesn't include a specific code for these procedures, but you might not have to resort to 64999 (Unlisted procedure, nervous system). Instead, you might be able to submit 62164 (Neuroendoscopy, intracranial; with excision of brain tumor, including placement of external ventricular catheter for drainage) for the tumor or cyst biopsies, depending on the extent of lesion removal.
Documentation check: Verify all the services your surgeon performed. If he didn't complete all services included in the descriptor you should append modifier 52 (Reduced services).
