Neurosurgery Coding Alert

Question: Several hours after CT-guided stereotactic brain biopsy, a patient developed a hematoma, which the neurosurgeon evacuated via craniotomy. He debulked the tumor at the same time. How should we report the latter procedures? Is the debulking included in the craniotomy?

Illinois Subscriber

Answer: If the surgeon performs the debulking at the same time as the hematoma drainage, the drainage is bundled into the debulking code (rather than vice-versa). Report 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) with modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) to indicate that the surgeon performed the procedure for therapy following a diagnostic surgical procedure.
 
If the surgeon only had drained the hematoma following biopsy, you would be correct to report 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) with modifier -58.