Neurosurgery Coding Alert

Avoid denials by avoiding modifier 51 with +69990 or +61781.

You typically report craniotomy as the principal component in cranial procedures. However, your surgeon may be performing additional procedures along with craniotomy. This is because cranial procedures are often complex. You may be missing out on your billing if you omit reporting any of these additional procedures and techniques. 

Watch out for these procedures next time you bill for cranial procedures. 

Keep a Count on Sessions for Microdissection 

When your surgeon uses the operating microscope for the purpose of microdissection, you report the microdissection code +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) in addition to the code of the primary craniotomy procedure. 

You do not bill multiple units of +69990 in an operative session. Regardless of how many times your surgeon uses the operating microscope for microdissection in a particular session in the OR, you report 69990 only once. “In addition, report the microdissection code +69990 immediately after the craniotomy code to enhance the likelihood of proper payment,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. “The microdissection code should always immediately follow the procedure code for which the microdissection is performed since there are a number of codes to which microdissection does not apply.”  Remember that this code is applicable once per operative session and not per procedure code. 

You look for terms like Weck, Zeiss or Leica operating microscope, which are brand names for microscopes, in the operative note to confirm the utilization of an operating microscope. “The surgeon should also describe the structure(s) which are being dissected with microdissection technique,” Przybylski says. 

Caution: Do not report the use of surgical loupes with +69990. “While surgical loupes provide magnification, the microdissection code +69990 is reported for the surgical work of microdissection using only the operating microscope,” Przybylski says. “This distinguishes surgical dissection applicable to every operation from actual microdissection.”

Confirm with your payer: You can check with your payer if you are allowed to report for the operating microscope. While CPT® allows microdissection to me applied to many more procedures, some payers may have a more limited list of procedures with which they will permit the use of +69990.

Example 1: If you read your neurosurgeon used the operating microscope to clip a small anterior communicating artery aneurysm without temporary clipping, you report code +69990 only once for the session in addition to the procedure code 61700 (Surgery of simple intracranial aneurysm, intracranial approach, carotid circulation).

Example 2: If you read your neurosurgeon performed a skull-based procedure to access an aneurysm, then performed a clip ligation of the aneurysm, you report codes 61583 (Craniofacial approach to anterior cranial fossa, intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal lobe, osteotomy of base of anterior cranial fossa) for the access and 61601 (Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; intradural, including dural repair, with or without graft) for the clip obliteration. In addition, you report code +69990 if your surgeon utilizes the operating microscope for microdissection to expose and dissect the vessels to secure the clips. 

Look For Anatomical Region for Navigation in Cranial Procedures

Depending upon whether your surgeon did the navigation intradurally or extradurally, you report codes +61781 (Stereotactic computer-assisted [navigational] procedure; cranial, intradural [List separately in addition to code for primary procedure]) or +61782 (Stereotactic computer-assisted [navigational] procedure; cranial, extradural [List separately in addition to code for primary procedure])). “Computer-assisted navigation allows the surgeon to integrate pre-operative imaging information from CT or MRI with the operative field to enhance safer exposure and targeting of desired structures,” Przybylski says.

Example 1: If your neurosurgeon performed resection of a frontal lobe astrocytoma using both microdissection with an operating microscope and neuronavigation, you would report 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) for the excision of the tumor. In addition, you report code +61781 for the stereotactic navigation and +69990 for the microdissection.

Example 2: If you read that your surgeon did a right-sided occipital stealth guided craniotomy for an open biopsy of a brain lesion which upon subsequent pathological analysis turned out to be “Metastatic carcinoma, poorly differentiated adenocarcinoma, lung primary,” you report code 61751 (Stereotactic biopsy, aspiration, or excision, including burr hole[s], for intracranial lesion; with computed tomography and/or magnetic resonance guidance) without 61781. “In this example, there is a specific CPT® code for biopsy that includes the work of stereotactic computer-assisted navigation,” Przybylski says.  If, however, your surgeon performs a craniotomy/craniectomy with navigation to excise the tumor, even if a biopsy is also performed, you report 61510 and 61781 as shown in Example 1.

Note: You can bill +61781 with 61510 as well as other craniectomy codes for tumor, cyst and abscess. Always list the navigation codes +61781 and +61782 immediately after the primary code (61510) for which the navigation system was used. “If microdissection is also used, the microdissection code should follow the craniotomy code and the navigation code should follow the microdissection code,” Przybylski says. “Also keep in mind CPT® codes that include the word “stereotactic” (CPT® 61720-61791) include the work of computer-assisted navigation and therefore neither 61781 nor 61782 should be reported,” Przybylski says.

Tip: Since codes +69990 and +61781 are add-on codes, you do not append modifier 51 (Multiple procedures) to either of these codes. 

Report Lumbar Drain as Distinct Procedure

Your surgeon may insert a lumbar drain to manage the pressure in the cranium during or after the surgical procedure. You report code 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]) for the lumbar drain. “Procedures in which a lumbar drain may be helpful include pituitary surgery and skull based procedures,” Przybylski says. “The use of the lumbar drain may facilitate both the intraoperative exposure of the target lesion as well as reduce the likelihood of postoperative CSF leak.”

Example: If you read your surgeon did a bone flap craniotomy adopting the extradural approach in the middle cranial fossa on the left side to repair an encephalocele and then inserted a spinal drain, you report code 62272 along with 62120 (Repair of encephalocele, skull vault, including cranioplasty) and append modifier 51 (Multiple procedures) to 62272 to specify that the insertion of the spinal drain and repair of the encepahlocele are two different and distinct procedures. 

Look For Approach in Ventriculostomy

When reporting ventriculostomy in cranial procedures, you will need to look at where the surgeon performed the ventriculostomy. If your surgeon places a drain for intraoperative ventricular decompression within the craniotomy exposure (i.e. does the ventriculostomy via the same burr hole or craniotomy incision), you do not independently report the drain as it is included in the craniotomy. “Minor procedures performed within the operative exposure of a major procedure are often considered incidental services that are bundled into the major procedure,” Przybylski says. 

If, however, your surgeon created a separate twist drill hole or burr hole to place the ventriculostomy, you may choose either 61107 (Twist drill hole[s] for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, other intracerebral monitoring device) or 61210 (Burr hole[s]; for implanting ventricular catheter, reservoir, EEG electrode[s], pressure recording device, or other cerebral monitoring device [separate procedure]). You report these codes as appropriate in addition to the craniotomy. 

Coding tip: You need to ensure your surgeon maintains adequate documentation in support of the independent approach for the ventriculostomy. You also append modifier 59 (Distinct procedural service) to 61107 or 61210 to indicate that the ventriculostomy was placed at a distinctly separate site from the craniotomy.