Otolaryngology Coding Alert

Question: An otolaryngologist and neurosurgeon are doing a surgery together. The patient has had a chronic cerebrospinal fluid (CSF) leak from a motor vehicle accident (MVA) that she was in a few years ago. She is an established patient of the otolaryngologist, who has attempted to repair the CSF leak but with no long-term success.

The two surgeons plan on performing a transnasal repair of the CSF leak. The technique is the same as if they were using the operating microscope to do a transnasal approach for the excision of a pituitary tumor (61548), but they are not removing anything, just closing the dura. I don't believe there is a code for this. Code 31291 describes surgical repair of a CSF leak in the sphenoid region (31291) using an endoscope, but the neurosurgeon said they wouldn't be using the endoscope. How should I report this procedure?

Ohio Subscriber

Answer: You should use the unlisted-procedure code for the nervous system: 64999-62 (Unlisted procedure, nervous system; co-surgery). Because you have to submit an unlisted- procedure code, send in a paper claim with a cover letter and documentation.

To help the insurer appropriately value the surgery (unlisted-procedure codes by virtue of definition contain no relative value units), the cover letter should compare/contrast the procedure with a similarly involved procedure. In the cover letter, equate the transnasal repair of the CSF leak to 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or transseptal approach, nonstereotactic). Explain that the surgeon performed the work involved in 61548, except he:

1. did not remove the pituitary gland and instead

2. repaired the dura.

Tip: Before the surgery, call the neurosurgeon's coder, and coordinate your claim. Payment hinges on you both agreeing to the coding, encouraging proper documentation and using the correct modifier. Because the otolaryngologist and neurosurgeon will be performing distinct parts of the same procedure, each coder will append modifier 62 (Two surgeons) to the agreed-upon procedure code, meaning 64999-62. Medicare and most other payers reimburse procedures coded with modifier 62 at 125 percent of the regular fee schedule amount.

Alert the surgeons that when you use 64999 with modifier 62, CMS requires documentation to establish medical necessity for two surgeons. Specifically, the documentation must show which special circumstances or skills required two surgeons to share responsibility. For example, altered anatomy from the previous CSF repairs may require the expertise of two surgeons.

The other code that you mention, 31291 (Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak; sphenoid region), does describe repairs to CSF leaks, but the code requires endoscopic repair of a sphenoid leak. The otolaryngologist may use the endoscope to enter the sphenoid directly through the septum or through the ethmoid sinuses..