Neurosurgery Coding Alert
Append Modifier 52 if Brain Tumor Was Not Removed
Question: How do we report a left temporoparietal craniotomy with an open brain tumor biopsy?
Florida Subscriber
Answer: For the procedure described, you may consider reporting code 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). This code, however, is for excision of the brain tumor. Since your surgeon is only doing a biopsy, you may append modifier 52 (Reduced services) if incomplete removal is performed. The craniotomy was followed by biopsy rather than excision (partial or complete) of the brain tumor. Hence, the procedure performed was less extensive than what the code typically reflects. Alternatively, CPT® 61304 may be reported for an exploratory supratentorial craniotomy/craniectomy.
Neurosurgery Coding Alert
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