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Question: The neurosurgeon is treating a 6-month-old patient with non-deformational dolichocephaly who needs a craniectomy for craniosynostosis. The patient’s parents present with the infant for surgery. The surgeon cuts into the patient’s skull over the affected area and removes the bone flap. They then remove the two cranial sutures to allow the skull to properly expand as the patient’s brain grows. I was going to report 61550 x 2 for the craniectomy with Q75.01 appended, but I’m not so sure about the diagnosis code. Would this be correct ICD-10-CM and CPT^® coding for this surgery?

Arkansas Subscriber

Answer: Actually, your diagnosis code choice is fine; it’s your CPT^® coding that needs correcting.

When you submit the claim, you should:

• Report 61552 (Craniectomy for craniosynostosis; multiple cranial sutures) for the craniectomy
• Append Q75.01 (Sagittal craniosynostosis) to 61552 to represent the patient’s non-deformational dolichocephaly

Explanation: The code you chose, 61550 (… single cranial suture), is for one cranial suture repair. Since the descriptor for 61552 includes multiple cranial sutures, you should report this code instead of 61550 x 2.

The ICD-10-CM code you chose, Q75.01, is correct because non-deformational dolichocephaly is listed as an alternate term for the diagnosis. Additionally, non-deformational scaphocephaly is also an alternate term you should code with Q75.01.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC