Neurosurgery Coding Alert

Tip: Don't forget retrieval services in your reporting.When your surgeon documents that he used a cranial bone flap during cranioplasty, review the record carefully to determine if he temporarily placed the graft in a subcutaneous pocket for "safe keeping" during an earlier operative session.If so, you should have reported an additional code for the initial placement - and you should be coding for the final retrieval and placement of the graft, as well.Step 1: Claim the Initial PlacementYou should select +61316 (Incision and subcutaneous placement of cranial bone graft [list separately in addition to code for primary procedure]) to describe temporary placement of a cranial bone graft into a distant subcutaneous site for future retrieval.The surgeon may choose to call on 61316, for instance, following decompressive craniotomy, when immediate placement of the bone flap may aggravate intracranial hypertension from brain swelling. In this case, the surgeon creates a subcutaneous pocket [...]