Code the Complexities of Pediatric Intracranial Endoscopies

Two points can help code these technologically advancing neurosurgery procedures.

By Samer K. Elbabaa, MD, FAANS, and G. J. Verhovshek, MA, CPC

Coding for intracranial neuroendoscopy is easier if you remember just two important points:

1.  With the exception of endoscopic assist for placement or replacement of ventricular catheter (which is an add-on service), all neuroendoscopic services are coded as “stand-alone” procedures.

2.  The National Correct Coding Initiative (NCCI) bundles “access” procedures, such as twist drill or burr holes, to neuroendoscopic procedures.

Neuoroendoscopy is a minimally invasive surgery, which when applied to intracranial surgery has resulted in positive outcomes for patients with specific pathologies. The goal of minimally invasive neurosurgical procedures is to reduce pain and blood loss, shorten recovery time, and reduce scarring.

Use Add-on and Primary Codes for ETV

Applications for the neuroendoscope include a wide range of procedures. Of these, endoscopic third ventriculostomy (ETV) is the most frequently performed. ETV has become a standard treatment for selected patients with symptomatic obstructive hydrocephalus.

Hydrocephalus is caused by disturbance of formation, flow, or absorption of cerebrospinal fluid (CSF), which leads to a buildup of fluid in the central nervous system (CNS). Incidence of congenital hydrocephalus (ICD-9 742.3x; or, with spina bifida, 741.0x) is three per 1,000 live births. To divert excess CSF, the surgeon places an intracranial shunt. A ventricular catheter in the brain is routed subcutaneously to another body area (for instance, the abdominal cavity) to allow the fluid to drain and be absorbed. A one-way, pressure-controlled valve regulates the flow of CSF through the catheter.

Primary coding for intracranial shunt placement is reported using CPT® codes 62220-62230, depending on the precise location of the shunt/drain and method of insertion. Primary coding for ETV, specifically, is reported using 62200 Ventriculocisternostomy, third ventricle or 62201 Ventriculocisternostomy, third ventricle; stereotactic, neuroendoscopic method if using stereotactic (navigational) guidance.

When any of the above procedures are performed using the neuroendoscope, report +62160 Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure) in addition to the primary code.

Per CPT® instruction, add-on code 62160 also may be reported with 61107 Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device and 61210 Burr hole(s); for implanting ventricular catheter, reservoir, EEG electrode(s), pressure recording device, or other cerebral monitoring device (separate procedure), as well as 62258 Removal of complete cerebrospinal fluid shunt system; with replacement by similar or other shunt at same operation for shunt removal and replacement.

Treat All Other Neuroendoscopes as “Primary” Procedures

Intracranial neuroendoscopy may be used for procedures other than ETV, such as biopsy or excision of intra-ventricular brain tumors, trans-sphenoidal excision of pituitary tumor, fenestration of colloid cyst, craniosynostosis, and more. Applicable CPT® codes include:

62161     Neuroendoscopy, intracranial; with dissection of adhesions, fenestration of septum pellucidum or intraventricular cysts (including placement, replacement, or removal of ventricular catheter)

62162                 with fenestration or excision of colloid cyst, including placement of external ventricular catheter for drainage

62163                 with retrieval of foreign body

62164                 with excision of brain tumor, including placement of external ventricular catheter for drainage

62165                 with excision of pituitary tumor, transnasal or trans-sphenoidal approach

Each of these codes should be reported as a “definitive” procedure, rather than an extra step. In other words, never report an endoscopy code in addition to the code that describes the identical “open” procedure. For example, you would report endoscopic fenestration of an intracranial cyst with 62162 alone—not in addition to the open code (61516 Craniectomy, trephination, bone flap craniotomy; for excision or fenestration of cyst, supratentorial).

On occasion, a surgeon may have to “convert” from an endoscopic procedure to an open procedure. When this occurs, report only the successful (open) procedure. Never report an endoscopic procedure and its open equivalent together.

Be Aware of Bundles

NCCI bundles access procedures 61105-61253, which describe twist drill, burr hole(s), or trephine, into neuroendoscopic procedures 62161-62165. As well, neuroendoscopic procedures may be mutually exclusive of other intracranial procedures. For example, NCCI lists 62164 as mutually exclusive of skull base surgery codes (61601, 61606-61608, and 61615-61616) and other procedures. Be sure to check NCCI thoroughly before billing neuroendoscopy with other intracranial procedures.

CPT® hasn’t added new intracranial neuroendoscopy codes since 2003, but coders are likely to see more procedures in the years ahead. Technological advances in endoscopic instrumentation will help surgeons to add new indications and approaches that are less traumatic compared to conventional open neurosurgery, and to improve visualization of pathologies.

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Samer K. Elbabaa, MD, FAANS, is director of pediatric neurosurgery and assistant professor of neurosurgery at Saint Louis University School of Medicine. His clinical practice focuses on minimally invasive neurosurgery, pediatric brain and spinal tumors, complex spinal instrumentation, cranio-cervical junction anomalies, neuro-endoscopy, and cerebrovascular surgery. Elbabaa’s research focuses on advancing endoscopic techniques in cranial and spinal neurosurgery.

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