Neurosurgery Coding Alert

Knowing the differences between the procedures is vital.

Naturally, neurosurgery coders are often presented with claims in which the surgeon has operated on a patient’s brain and skull. Two of the more common procedures of this type are craniotomy and craniectomy.

You’ll have a few obstacles to overcome on your way to the correct craniotomy/craniectomy code choice. There’s a slew of codes for these surgeries, and picking the right one isn’t always easy.

Help’s here: We spoke with Suzanne Quinton, CPC, CPC-I, COSC, owner of Quinton Coding Consultants, Inc. in Broken Arrow, Oklahoma, about the intricacies of craniotomy/ craniectomy coding. Here’s what she had to say.

Know Craniotomy/Craniectomy Differences

The first thing you’ll need to learn is the difference between a craniotomy and a craniectomy. “A craniotomy is a procedure in which part of the skull is temporarily removed,” Quinton explains. The surgeon could use craniotomy to treat hematoma, remove brain tumors, and more. Once the surgery is complete during craniotomy, the skull piece is replaced when the procedure is finished.

“A craniectomy is a surgical procedure performed when the portion of the skull removed during brain surgery. The skull piece is not put back when the procedure is finished,” says

Quinton. The reason for a craniectomy is to create room for brain swelling after traumatic injury, removing infected portions of the skull, or removing portions of the skull where traumatic injury has resulted in multiple fragments.

You’ll Use Some Codes More Than Others

When you turn to the craniotomy/craniectomy code section of CPT^®, you might feel a bit overwhelmed. There are more than 50 codes to choose from, so you need to have notes that are thorough and on point in order to select the correct surgical code.

While any neurosurgeon could perform any of the craniotomies/craniectomies listed, there are some surgeries that are more common than others. Here’s a sampling of the codes Quinton uses most often for these surgeries:

• 61304 (Craniectomy or craniotomy, exploratory; supratentorial)
• 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural)
• 61320 (Craniectomy or craniotomy, drainage of intracranial abscess; supratentorial)
• 61343 (Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (eg, Arnold-Chiari malformation))
• 61458 (Craniectomy, suboccipital; for exploration or decompression of cranial nerves)
• 61500 (Craniectomy; with excision of tumor or other bone lesion of skull)
• 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma)
• 61512 (Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial)
• 61546 (Craniotomy for hypophysectomy or excision of pituitary tumor, intracranial approach)
• 62100 (Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea)

Remember: “Some of these codes are further divided by the location of the work: supratentorial or infratentorial, extradural, intradural, intracerebral,” according to Quinton.

Check for Additional Services

There are also a few additional services that you’ll code in addition to craniotomy/ craniectomy, when performed. “In addition to a craniotomy or craniectomy, there will likely be an inpatient consultation or an admitting history and physical exam by the neurosurgeon,” says Quinton. Sometimes this will be separately codeable; other times it might be part of the surgical package.

If you do code for an evaluation and management (E/M) service the day of (or day before) craniotomy/craniectomy, remember to add modifier 57 (Decision for surgery) to the E/M code.

There are also a few non-E/M services that you might code separately in addition to your primary craniotomy/craniectomy code. These services include:

• +61781 (Stereotactic computer-assisted (navigational) procedure; cranial, intradural (List separately in addition to code for primary procedure)) and
• +61782 (… cranial, extradural (List separately in addition to code for primary procedure)).
•  62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)) and 62329 (… with fluoroscopic or CT guidance).
•  61210 (Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure)).
• +61517 (Implantation of brain intracavitary chemotherapy agent (List separately in addition to code for primary procedure)).

Check Out These Examples

Now that we’ve run down the basics, here’s an example of a craniotomy (provided by Quinton) and one of a craniectomy, provided by Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey:

EXAMPLE 1: CRANIOTOMY

Clinical presentation: An 88-year-old woman was transferred from an outlying facility due to a recent fall in which she hit her head. The patient had no loss of consciousness, was alert and oriented, and complaining of headache, dizziness, and blurry vision. The patient has a history of low-dose aspirin use daily. Computed tomography (CT) of the head was notable for a large right subdural hematoma. The neurosurgeon examined and spoke to the patient and the decision was made to take the patient to the operating room on an urgent basis. Notes indicate a comprehensive history and examination, along with moderate-level medical decision making (MDM).

OP Note:

Preoperative diagnosis: Large right acute subdural hematoma with mass effect Postoperative diagnosis: Large right acute subdural hematoma with mass effect

Procedure performed:

1. A Right-sided craniotomy for evacuation of large acute subdural hematoma
2. Use of Mayfield headholder.

Coding:

For this claim, you’ll report:

• 61312 for the craniotomy.
• 99222 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. …) with modifier 57 appended to represent the presurgical consultation.

EXAMPLE 2: CRANIECTOMY

Clinical presentation: A 56-year-old man was admitted through the emergency room with headache, nausea, incoordination, and double vision. He had known lung cancer. MRI of the brain revealed a left cerebellar enhancing mass consistent with a metastasis. Hydrocephalus was also noted because of compression of the fourth ventricle. Computed tomography (CT) of the chest, abdomen and pelvis was unremarkable. The patient became more lethargic and consultation with the neurosurgeon prompted recommendation of emergent placement of a ventricular drain and surgical excision with microdissection technique. Notes indicate a comprehensive history and examination, along with high-level medical decision making (MDM).

OP Note:

Preoperative diagnosis: Left cerebellar metastasis with obstructive hydrocephalus

Postoperative diagnosis: Left cerebellar metastasis with obstructive hydrocephalus

Procedure performed:

1. Left suboccipital craniectomy with excision of cerebellar metastasis
2. Placement of right frontal ventricular drain

Coding:

For this claim, you’ll report:

• 61518 for the craniectomy.
• +69990 (Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)) for microdissection.
• 61210 for the separate site ventricular catheter placement.
• Modifier 59 (Distinct procedural service) appended to 61210 to show that the catheter placement is separate from the craniectomy.
• 99255 (Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and medical decision making of high complexity. …) OR 99223 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. …) for the consultation E/M. (If the payer is like Medicare and doesn’t accept consult codes any longer, you’ll have to opt for 99223.)
• Modifier 57 appended to 99255 OR 99223 to show that the E/M service was a separate service from the craniectomy.