Neurosurgery Coding Alert

Question: Can we code for two aneurysms when they are approached through the same incision? Our surgeon performed the following procedures:

1. Right frontotemporal sphenoidal craniotomy

2. Anterior skull base approach with modified orbitofrontal craniotomy

3. Microdissection and use of operating microscope

4. Microsurgical clipping of ruptured A1-A2-Acomm junction aneurysm of complex morphology with deliberate proximal temporary artery occlusion (2 minutes)

5. Microsurgical clipping of unruptured anterior communicating artery aneurysm of complex morphology

6. Intraoperative ventriculostomy (Paine's point)

Illinois Subscriber

Answer: When both aneurysms are within the same surgical exposure, you would only report one craniotomy code for treatment of the aneurysm. However, the additional work of treating the associated second aneurysm can be reported by appending the 22 (Increased Procedural Services) modifier to the craniotomy code. While the brief summary provided describes a skull base technique for exposure, one should be aware that the skull base surgery codes are applied for skull base techniques when another specific craniotomy code is not available.

The craniotomy for aneurysm codes (61607-61702) are procedures performed at the skull base as well. The ventriculostomy was likely placed within the craniotomy as described and is consequently considered a bundled service. Since temporary occlusion was used, one would report 61697(Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation) -22 and 69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]).