Neurosurgery Coding Alert

Do you know that craniomegalic skull is present at birth?

Neurosurgery is always a delicate matter, particularly when you’re dealing with infants and young children as patients.

There are a pair of conditions that infants suffer from that neurosurgeons will often work to correct: craniomegalic skull and encephalocele. Each of these conditions has their own sets of diagnosis codes and surgical codes for you to report.

Read on to check out the pair of conditions, and how to report the surgeries when your neurosurgeon treats them.

Use These Codes for Craniomegalic Skull Fix

Craniomegaly (head enlargement), which is also termed macrocephaly, describes patient’s condition when their head circumference exceeds the 97th percentile (two standard deviations) for that individual’s age, gender and race. This can be related to benign familial conditions or underlying causes that can lead to developmental delay and neurological deficits.

Head enlargement can result from increased brain parenchyma and/or increased cerebrospinal fluid, and can be associated with hydrocephalus. There are a number of genetic syndromes that are associated with craniomegaly.

ICD-10 codes: Some of the diagnoses that could lead tocraniomegalic skull repair include the following:

• G91.0 (Communicating hydrocephalus)
• G91.1 (Obstructive hydrocephalus)
• G91.2 ((Idiopathic) normal pressure hydrocephalus)
• G91.3 (Post-traumatic hydrocephalus, unspecified)
• M95.2 (Other acquired deformity of head)
• Q03.0 (Malformations of aqueduct of Sylvius)
• Q03.1 (Atresia of foramina of Magendie and Luschka)
• Q05.4 (Unspecified spina bifida with hydrocephalus)
• Q05.9 (Spina bifida, unspecified)
• Q07.02 (Arnold-Chiari syndrome with hydrocephalus)

Note: This is not a complete list of ICD-10 codes for craniomegalic skull conditions; always code to the notes and ask the provider if you’re unsure. Also, this list does not represent approved diagnoses for craniomegalic skull treatments. Check your payer contract for more information regarding treatment for craniomegalic skull.

When the surgeon performs surgery to treat the patient’s craniomegalic skull, you’ll report one of the following codes:

• 62115 (Reduction of craniomegalic skull (eg, treated hydrocephalus); not requiring bone grafts or cranioplasty)
• 62117 (… requiring craniotomy and reconstruction with or without bone graft (includes obtaining grafts))

Example: A 30-month-old patient with hydrocephalic macrocephaly was successfully treated for their hydrocephalus related to aqueductal atresia with an endoscopic third ventriculostomy. However, their head size made it difficult for the patient to achieve head control. Their head circumference was greater than the 99th percentile for their age, race and gender. A surgical reduction of the craniomegalic skull without bone grafting or cranioplasty was recommended.

For this encounter, you’d report 62115 for the skull reduction with Q03.0 (Malformations of aqueduct of Sylvius) appended to represent the patient’s condition.

Use These Codes for Encephalocele Repair

Another condition that affects infants is encephalocele. According to the National Institutes of Health (NIH), “encephalocele is usually a congenital type of neural tube defect, where a sac containing brain/meninges/cerebrospinal fluid forms outside the skull due to a bone defect. On occasions, acquired encephaloceles may result from trauma, tumors, or iatrogenic injury.”

According to Nationwide Children’s Hospital, “Signs of encephalocele can include:

• “Too much fluid in the brain (called hydrocephalus)
• “Loss of strength in the arms and legs
• “A small head
• “Awkward movement of muscles, such as those used in walking and reaching
• “Delay in growth and development
• “Problems seeing
• “Problems with breathing, heart rate, and swallowing
• “Seizures”

ICD-10 codes: Some of the diagnoses that could triggerencephalocelerepair include the following:

• I67.850 (Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy)
• Q01.0 (Frontal encephalocele)
• Q01.1 (Nasofrontal encephalocele)
• Q01.2 (Occipital encephalocele)
• Q01.8 (Encephalocele of other sites)
• Q01.9 (Encephalocele, unspecified)
• Q02 (Microcephaly)
• Q03.0
• Q03.1
• Q04.4 (Septo-optic dysplasia of brain)
• Q04.5 (Megalencephaly)
• Q04.6 (Congenital cerebral cysts)

Note: This is not a complete list of ICD-10 codes for encephalocele conditions; always code to the notes and ask the provider if you’re unsure. Also, this list does not represent approved diagnoses for encephalocele treatments. Check your payer contract for more information regarding treatment for encephalocele.

When your surgeon opts for encephalocele repair, choose one of the following codes:

• 62120 (Repair of encephalocele, skull vault, including cranioplasty)
• 62121 (Craniotomy for repair of encephalocele, skull base)

Example: A newborn was known to have an occipital encephalocele based on prenatal ultrasound at 16 weeks. The mother did not wish to pursue an amniocentesis because of its associated risks. In utero magnetic resonance imaging (MRI) at 28 weeks confirmed a small occipital encephalocele. The neonate was born by vaginal delivery at 38 weeks of gestational age and physical examination confirmed a 2 cm diameter encephalocele. The neurosurgeon consulted recommended a repair of the occipital encephalocele with cranioplasty.

For this encounter, you’d report 62120 for the encephalocele repair with Q01.2 (Occipital encephalocele) appended to represent the patient’s condition.