Neurosurgery Coding Alert

Question: Which code is appropriate if the surgeon places a bone flap in a subcutaneous pocket in the belly? The surgeon said he placed the bone flap for storage to repair the skull at a later time. Would 49000 work?

Pennsylvania Subscriber

Answer: You should not report 49000 (Exploratory laparotomy, exploratory celiotomy with or without biopsy[s] [separate procedure]) for subcutaneous placement of a bone flap.

Instead, call upon +61316 (Incision and subcutaneous placement of cranial bone graft).

During craniectomy or craniotomy for exploration, evacuation of hematoma, decompression or other indicated purpose, the surgeon will remove a portion of bone from the skull to allow for intracranial access. If replacement of the bone flap may aggravate intracranial hypertension from brain swelling, the surgeon may choose to create a subcutaneous "pocket" in the patient's abdominal wall in which to place the bone flap for safe keeping. At a later date, when brain swelling has subsided, the surgeon will remove the stored flap and replace it into the skull for repair and reconstruction.

Notice that +61316 is an add-on code, which you must use along with an approved primary procedure code. Approved primary procedures, according to CPT, are 61304, 61312, 61313, 61322, 61323, 61340, 61570, 61571, 61680-61705.