Neurosurgery Coding Alert

Published on Mon May 02, 2016 PDF

Look for specific codes for pituitary, pineal, and carotid body tumors.

With surgery being the preferred treatment for benign central tumors, you are likely to face the need for coding this diagnosis. The commonest benign tumors that your surgeon may operate upon include pineal gland tumors, benign pituitary tumors, craniopharyngiomas, and carotid body tumors. You needn’t struggle to report any of these diagnoses as there are definitive codes for each of these benign tumors.

Distinguish Pituitary Tumor and Craniopharyngioma

Most tumors in the pituitary are benign. These tumors appear as an abnormal growth in the pituitary gland.

Tumor size determines the symptoms: The diagnosis of a pituitary mass may be an incidental finding on an MRI or CT scan if the pituitary tumor is small and does not produce any hormones. Pituitary tumors may produce one or more hormones in excess and lead to symptoms like gigantism, Cushing’s syndrome, galactorrhea, decreased sexual function, and others. Large pituitary tumors may cause mass effects like headache, nausea and vomiting, double vision, and dropping eyelids.

However, similar symptoms may be caused by a craniopharyngioma which is a benign tumor arising from a craniopharyngeal duct. Such tumors can often grow to more than 3 cm in size and press upon the pituitary stalk or the pituitary gland. This may lead to partial or complete deficiency of one or more pituitary hormones.

ICD-10-CM offers specific codes: For benign tumors of the pituitary gland, you submit ICD-10-CM code D35.2 (Benign neoplasm of pituitary gland). However, when your physician documents craniopharyngioma, you report ICD-10-CM code D35.3 (Benign neoplasm of craniopharyngeal duct).

Target Single Code for Benign Pineal Neoplasms

When your physician makes a diagnosis of a benign tumor of pineal gland, you submit ICD-10 code D35.4 (Benign neoplasm of pineal gland).

What is pineal gland? The pineal gland is a structure in the brain that produces a hormone called melatonin which plays an important role in controlling sleep. Tumors in the pineal gland may grow to compress the surrounding structures. Depending upon the structures that the tumorous mass compresses, the patient may experience headaches, vomiting, visual disturbances, balance and coordination problems, and hormonal imbalances.

Consider Paragangliomas as Benign Tumors

Your physician may document a diagnosis of paraganglioma in a patient with a painless mass in the neck. Also called carotid body tumor, the carotid paragangliomas though rare, are the commonest head and neck paragangliomas. These benign tumors arise from embryonic neuronal cells. Sometimes, these tumors may present with symptoms of cranial nerve involvement, most commonly the vagus nerve. For the diagnosis of carotid paraganglioma, you submit code D35.5 (Benign neoplasm of carotid body). Most paragangliomas are benign.