Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon performed the following procedures:

1. Approach: Infratemporal pre-auricular approach, middle cranial fossa without mandible disarticulation with parotidectomy, craniotomy
2. Definitive procedure: Excision of infectious lesion, pharyngeal space, intradural without graft
3. Repair: Repair of defect using local pedicle flap.

How many codes should I be reporting for this encounter?

Massachusetts Subscriber

Answer: As long as the notes don’t indicate any other procedures or services, you’ll report three codes. On your claim, report:

• 61590 (Infratemporal pre-auricular approach to middle cranial fossa (parapharyngeal space, infratemporal and midline skull base, nasopharynx), with or without disarticulation of the mandible, including parotidectomy, craniotomy, decompression and/or mobilization of the facial nerve and/or petrous carotid artery) for the approach.

61606 (Resection or excision of neoplastic, vascular or infectious lesion of infratemporal fossa, parapharyngeal space, petrous apex; intradural, including dural repair, with or without graft) for the definitive procedure. The lesser valued of these procedures (in this case CPT^® 61606) would be appended with the -51 multiple procedure modifier.

The closure would typically be considered inclusive of the approach. One would not report CPT^® 61619 (Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by local or regionalized vascularized pedicle flap or myocutaneous flap (including galea, temporalis, frontalis or occipitalis muscle)) for the defect repair. Either CPT^® 61618 and 61619, depending on the type of closure, are reported for the “secondary” repair of a CSF leak that occurs at some time after the patient’s index surgery. Neither of these codes are applicable to the initial closure.

CPT^® definition: The introductory section to the code set Surgery of Skull Base has some illuminating information about this series of surgeries. According to CPT^®, “the procedures are categorized according to:

• “Approach procedure necessary to obtain adequate exposure to the lesion (pathologic entity);
• “Definitive procedure(s) necessary to biopsy, excise or otherwise treat the lesion;
• “Repair/reconstruction of the defect present following the definitive procedure(s).”