Otolaryngology Coding Alert

Question: I’m struggling to code an operative note that involves the excision of a tumor on the base of the skull. The surgeon excised this tumor via an endoscopic method through the sinuses. Can I report code 62165 without a pituitary tumor diagnosis?

Florida Subscriber

Answer: You are correct that code 62165 (Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach) should be reserved for neuroendoscopic excisions of an established pituitary tumor. You’ll also find no existing code for a benign or malignant neoplasm of the base of the skull that falls under the ICD-10-CM coding crosswalk for code 62165.

Unfortunately, there’s no existing code in the CPT^® book that aligns with the work performed by your physician. You will need to submit this claim on paper using 64999 (Unlisted procedure, nervous system) and include all the necessary documentation. Furthermore, you may use code 62165 as a comparison code in box 19 of the claim, so the payer has a gauge for the extent of work performed.