Neurosurgery Coding Alert

Question: A new patient reports to the neurosurgeon with headaches, neck pain, and coordination problems. The surgeon performs a thorough review of the patient’s symptoms and medical history. The surgeon conducts tests to gauge the patient’s motor skills, sensory function, and balance. Total encounter time for the evaluation and management (E/M) service was 65 minutes. Then, the surgeon orders a brain magnetic resonance imaging (MRI) with contrast materials (on the same day). The surgeon performs supervision of the MRI and, after interpreting the MRI results, the surgeon diagnoses the patient with “Chiari synd, no hydroceph./ SB.” How should I report this encounter, and what is Chiari syndrome?

Montana Subscriber

Answer: For this encounter, your surgeon diagnosed a patient with Chiari malformation (or syndrome) without hydrocephalus and/or spina bifida. On your claim, report:

• 70552 (Magnetic resonance (eg, proton) imaging, brain (including brain stem); with contrast material(s)) for the MRI
• 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99205 to show that the E/M and MRI were significant, separately identifiable services
• Q07.00 (Arnold-Chiari syndrome without spina bifida or hydrocephalus) appended to 70552 and 99205 to represent the patient’s condition

More on Chiari: According to Johns Hopkins Medicine, “a Chiari malformation is a problem in which a part of the brain (the cerebellum) at the back of the skull bulges through a normal opening in the skull where it joins the spinal canal. This puts pressure on parts of the brain and spinal cord, and can cause mild to severe symptoms.”

As previously noted, spina bifida or hydrocephalus (or both) can accompany a Chiari malformation. For those patients, you’ll choose from one of these diagnosis codes, depending on encounter specifics:

• Q07.01 (Arnold-Chiari syndrome with spina bifida)
• Q07.02 (Arnold-Chiari syndrome with hydrocephalus)
• Q07.03 (Arnold-Chiari syndrome with spina bifida and hydrocephalus).