Neurosurgery Coding Alert

Craniotomy cases can be some of your toughest to code because of all the potential variables -- and because even though you'll submit only one code for the craniotomy, you might be able to code additional services during the encounter.

See how to work through the procedure step by step and determine what can be coded, based on this information from subscriber Rogelyn Johnson, neuroscience medical coder with INOVA Fairfax Hospital in Virginia.

The case: The surgeon performed a right transfrontal ventriculostomy and right parieto occipital craniotomy to remove a pineal region mass. It included opening of the tentorium and resection of an infratentorial and supratentorial tumor. The physician's diagnosis was pineal region mass, supretentorial, and infratentorial, plus hydrocephalus.

May we code the Mayfield head holder in addition to other parts of the surgery?

Starting point: Placing the patient in a Mayfield head holder or any other fixation device is considered part of the craniotomy surgery and is not separately reportable, says Betsy Donnelly, CPC, PCS, a multispecialty coder with Martin Memorial Health Systems in Stuart, Fla. You do have several other factors to consider, however, before submitting the claim.

Johnson's scenario mentions a right parieto occipital craniotomy, which takes place above the tentorium. Based on this information, the appropriate code is 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma).

Extra work: You might also need to append modifier 22 (Increased procedural services) to 61510 in order to reflect the additional work involved in the tumor removal since it extended below the tentorium into the infratentorial area. Be sure your physician's documentation clearly demonstrates the additional work before you code it.

Back-up plan: Different techniques, however, can change your coding,. If you're coding a similar case and your surgeon uses a predominantly infratentorial approach, report 61518 (Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningioma, cerebellopontine angle tumor, or midline tumor at base of skull) instead of 61510.

"61510 and 61518 are not usually billed together because one is supratentorial and one is infratentorial," Donnelly says. "Your doctor needs to perform a completely separate craniotomy to bill both."

In our example case, you can also report the burr hole and ventriculostomy because the surgeon used a separate site from the craniotomy. You have two choices, depending on the neurosurgeon's technique:

• 61107 -- Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device

• 61210 -- Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure).

"Documentation will need to be clear to show whether a twist drill or burr hole was done to place the catheter," Donnelly says. "In either case, the hole creation is billable since it's a different location than the craniotomy."

Once you determine the correct code, append modifier 59 (Distinct procedural service) to show that the hole creation and ventriculostomy placement are separate from the craniotomy.

Sometimes, the equipment your surgeon uses helps boost your claim, so double-check the operative report for special notes.

Example: If your physician registered and used the stereotactic intraoperative wand guidance system (such as the Stealth Neuronavigation) and the microscope for microdissection of the tumor, you could report two additional codes:

• +61795 -- Stereotactic computer-assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal (List separately in addition to code for primary procedure)

• +69990 -- Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure).