Neurosurgery Coding Alert

Never ignore the add-on procedure in a craniotomy.

When reporting cranial procedures, you typically only need to consider one principal component: the craniotomy. Since cranial procedures are often complex, you may very often need to report additional procedures and techniques. Read on to know the add-on codes you can frequently report for your neurosurgery billing.

Report Microdissection Only Once Per Session

When your surgeon uses the operating microscope, you report the microdissection code +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) in addition to the code of the primary craniotomy procedure.

You do not bill multiple units of 69990 in an operative session. Regardless of how many times your surgeon uses the operating microscope in a particular session in the OR, you report 69990 only once. "In addition, report the microdissection code 69990 immediately after the craniotomy code to enhance the likelihood of proper payment," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. Remember that this code is applicable once per operative session and not per procedure code.

You look for terms like Weck, Zeiss or Leica operating microscope in the operative note to confirm the utilization of an operating microscope.

Caution: Do not report the use of surgical loupes with 69990. "The use of surgical loupes for magnification is not separately reportable," says Przybylski.

Confirm with your payer: You can check with your payer if you are allowed to report for the operating microscope. Some payers may have a list of procedures with which they will permit the use of 69990.

Example 1: If you read that your neurosurgeon used the operating microscope to clip a small anterior communicating artery aneurysm without temporary clipping, you report code 69990 only once for the session in addition to the procedure code 61700 (Surgery of simple intracranial aneurysm, intracranial approach, carotid circulation).

Example 2: If you read that your neurosurgeon performed a skull-based procedure to access an aneurysm, then performed a clip ligation of the aneurysm, you report codes 61583 (Craniofacial approach to anterior cranial fossa, intradural, including unilateral or bifrontal craniotomy, elevation or resection of frontal lobe, osteotomy of base of anterior cranial fossa) for the access and 61601 (Resection or excision of neoplastic, vascular or infectious lesion of base of anterior cranial fossa; intradural, including dural repair, with or without graft) for the clip obliteration. In addition, you report code 69990 if your surgeon utilizes the operating microscope for microdissection to secure the clips.

Look For Anatomical Region for Navigation in Cranial Procedures

Depending upon whether your surgeon did the navigation intradurally or extradurally, you report codes 61781 (Stereotactic computer-assisted [navigational] procedure; cranial, intradural [List separately in addition to code for primary procedure]) or 61782 (Stereotactic computer-assisted [navigational] procedure; cranial, extradural [List separately in addition to code for primary procedure])).

Example 1: If your neurosurgeon performed resection of a frontal lobe astrocytoma using both microdissection with an operating microscope and neuronavigation, you would report 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) for the excision of the tumor per se. In addition, you report code 61781 for the stereotactic navigation and 69990 for the microdissection.

Example 2: If you read that your surgeon did a right-sided occipital stealth guided craniotomy for an open biopsy of a brain lesion which upon subsequent pathological analysis turned out to be "Metastatic carcinoma, poorly differentiated adenocarcinoma, lung primary," you report code 61140 (Burr hole[s] or trephine; with biopsy of brain or intracranial lesion) and 61781. If, however, your surgeon excises the tumor, you report 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorialosterior fossa; except meningioma) and 61781.

Note: You can bill 61781 with 61510 as well as other craniectomy codes for tumor, cyst and abscess. Always list the navigation codes 61781 and 61782 immediately after the primary code (61510) for which the navigation system was used. "If microdissection is also used, the microdissection code should follow the craniotomy code and the navigation code should follow the microdissection code," says Przybylski.

Tip: Since codes 69990 and 61781 are add-on codes, you do not append modifier 51 (Multiple procedures) to either of these codes.

Report Lumbar Drain as Distinct Procedure

Your surgeon may insert a lumbar drain to manage the pressure in the cranium after the surgical procedure. You report code 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]) for the lumbar drain. "This may be done after procedures in which the risk of postoperative CSF leak is high, such as transpheniodal surgery for pituitary tumors," says Przybylski.

Example: If you read that your surgeon did a bone flap craniotomy adopting the extradural approach in the middle cranial fossa on the left side to repair an encephalocele and then inserted a spinal drain, you report code 62272 along with 62120 (Repair of encephalocele, skull vault, including cranioplasty) and append modifier 51 (Multiple procedures) to 62272 to specify that the insertion of the spinal drain and repair of the encepahlocele are two different and distinct procedures.

Look For Approach in Ventriculostomy

When reporting ventriculostomy in cranial procedures, you will need to look at where the surgeon performed the ventriculostomy. If your surgeon places a drain for intraoperative ventricular decompression within the craniotomy, i.e. does the ventriculostomy via the same burr hole or craniotomy incision, you do not independently report the drain as it is included in the craniotomy. "Minor procedures performed within the operative exposure of a major procedure are often considered incidental services that are bundled into the major procedure," says Przybylski.

If , however, your surgeon created a separate twist drill hole or burr hole to place the ventriculostomy, you may choose either 61107 (Twist drill hole[s] for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, other intracerebral monitoring device) or 61210 (Burr hole[s]; for implanting ventricular catheter, reservoir, EEG electrode[s], pressure recording device, or other cerebral monitoring device [separate procedure]). You report these codes as appropriate in addition to the craniotomy.

Coding tip: You need to ensure your surgeon maintains adequate documentation in support of the independent approach for the ventriculostomy. You also append modifier -59 (Distinct procedural service) to 61107 or 61210 to indicate that the ventriculostomy was placed at a distinctly separate site from the craniotomy.