Neurosurgery Coding Alert

Question: Our surgeon did a ventriculoscopy and fenestrated a cystic tumor in the third ventricle and placed a ventriculoperitoneal shunt. How do we report this?

Florida Subscriber

Answer: Make note that you report the two procedures that your surgeon is doing. First the endoscopic cyst fenestration for which you report code 62161 (Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts [including placement, replacement, or removal of ventricular catheter]) and second the VP shunt for which you report code 62223 (Creation of shunt; ventriculo-peritoneal, -pleural, other terminus). You should append modifier 51 (Multiple procedure…..) to code 62223 to imply that your surgeon is doing multiple procedures.