Neurosurgery Coding Alert

Question: My physician coded 61510 x 3 because the tumor overlapped several areas. His documentation states, "left frontotemporal craniotomy with stealth neuronavigation system. Frameless stereotactic volumetric resection of invasive metastatic carcinoma." A small piece of soft tissue adherent to the bone flap confirmed adenocarcinoma, so he placed a titanium mesh plate and screws instead of replacing the bone flap. Should I follow my physician's coding advice?

Connecticut Subscriber

Answer: Your physician is thinking of the correct code, but he wants to report it too many times. Code 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) represents everything supratentorial.

It appears that your surgeon performed one craniotomy and made a single incision, so you report 61510 only once. Then add +61795 (Stereotactic computer-assisted volumetric [navigational] procedure, intracranial,

extracranial, or spinal [List separately in addition to code for primary procedure]) for the stealth navigation.

Modifier note: If your surgeon incised more than one area, you might be able to append modifier 59 (Distinct procedural service) for additional incisions and separate tumor excision. Depending on his documentation, you also might be justified in alternatively reporting modifier 22 (Increased procedural services) because of the tumor's size and the additional work to complete the procedure.