Neurosurgery Coding Alert

Tip: Confirm craniotomy and procedure for orbital pathology.

When your neurosurgeon accesses orbital lesions using a transcranial approach, you’ll need to ascertain what procedure in specific your surgeon performed for the orbital pathology. Do not forget to locate the exact details in the surgical note that help you to confirm the transcranial approach to the orbit.

Step 1: Confirm Craniotomy to Report Transcranial Approach

When reporting orbital exploration, the first step for you is to look for craniotomy to confirm that your surgeon used a transcranial approach to reach the orbit. Take a look at the details in the example below to see what’s needed.

Example: You may read that your neurosurgeon planned a transcranial approach in a patient with a tumor at the orbital apex. The operative indicates that after making a bicoronal incison, your surgeon made a burr hole to expose periorbita on its lower edge and frontal dura on its upper edge. You then see that "an orbitofrontal bone flap was raised, the frontal lobe retracted, and the thin part of the roof of the orbit behind the orbital rim was opened."

Proof: The craniotomy with removal of the roof of the orbit confirms the intracranial approach to the orbit.

Keep in mind: The transcranial approach includes the fronto-orbital, fronto temporo-orbital, subfrontal, or the pterional approaches. "There are a variety of intracranial approaches to the orbit, but they all have in common a craniotomy for removal of bone with subsequent retraction of the frontal lobe(s) to access the orbital roof," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. You need to make sure you document what each surgeon did and why the services of each were needed.

Step 2: Ascertain the Definitive Procedures

In addition to identifying the approach, you will need to report any additional service your surgeon provided, for example, biopsy, exploration, decompression, removal of lesion or foreign body.

If you read that your surgeon only performed an orbital decompression to relieve the pressure on the optic nerve, you report code 61330 (Decompression of orbit only, transcranial approach). If your surgeon explores the orbit and just obtains a biopsy, you report code 61332 (Exploration of orbit [transcranial approach]; with biopsy).

On the other hand, you may read that the orbital exploration was to remove either a tumor or a foreign body. In this case, you report code 61333 (Exploration of orbit [transcranial approach]; with removal of lesion) and 61334 (Exploration of orbit [transcranial approach]; with removal of foreign body) for removal of the tumor and foreign body, respectively. "Each of these codes have a craniotomy approach in common. The difference lies in the additional intraorbital work performed," says Przybylski.

Caution: Do not confuse these codes with the skull base approach. Your surgeon may do a right orbital craniectomy and removal of intraorbital tumor. You report code 61333 for the tumor removal in this case. If, however, your surgeon used a skull base technique, then you report the anterior fossa approach using 61584 (Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe[s]; without orbital exenteration) or 61585 (Orbitocranial approach to anterior cranial fossa, extradural, including supraorbital ridge osteotomy and elevation of frontal and/or temporal lobe[s]; with orbital exenteration) to describe the orbital tumor removal. "Use of the skull base surgery codes requires both an approach and a related definitive procedure code," says Przybylski.