Neurosurgery Coding Alert

Skull base surgeries often require the skills of several surgeons of different specialties and are broken down into three kinds of procedures (approach, definitive and repair/reconstruction) creating complex coding issues for the neurosurgeon involved. By not documenting and coding correctly, you may not receive reimbursement for the procedure you have performed.

Skull base coding is even more involved because the approach procedures are broken down into the anterior cranial fossa, middle cranial fossa and posterior cranial fossa, depending on which of three different directions the neurosurgeon uses to approach the brain. The definitive procedures performed after the approach is made are broken down into the base of the anterior cranial fossa, base of the middle cranial fossa, and base of the posterior cranial fossa depending on precisely where the problem lies in the base of the brain. Precise documentation is essential for proper coding as the difference of only a few centimeters in the initial incision may affect the code range that should be employed.

Coding for Co-Surgeons

Skull base surgeries often are performed with the assistance of other surgeons including otolaryngologists and oral surgeons. In these cases, the codes are billed according to who performed them and if they were performed with or without assistance. According to CPT 2000, When one surgeon performs the approach procedure, another surgeon performs the definitive procedure, and another surgeon performs the repair/reconstruction procedure, each surgeon reports only the code for the specific procedure performed. If one surgeon performs more than one procedure (i.e., approach procedure and definitive procedure), then both codes are reported, adding modifier -51 (multiple procedures) to the secondary additional procedures.

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, and a coder who specializes in surgical and neurosurgical procedures, states that if the neurosurgeon performs the approach and the definitive procedure and then the otolaryngology surgeon performs the closure (closing the dura, putting the bone back in, sewing up the soft tissue), then they both should code the approach procedure and use the -62 modifier (two surgeons) to indicate that it was a co-surgical procedure between the neurosurgeon and the otolaryngology surgeon. The neurosurgeon also would code for the definitive procedure with the -51 modifier.

Coding the Approach Procedures

Arlene Liestman-Phillips, CPC, RHIT, professional services coder for neurosurgery and neurology at Oregon State University in Portland, reports that she runs into problems when the neurosurgeons document a modified approach in their operative notes. Liestman-Phillips cites a modified orbital zygomatic approach, which might be coded 61592 (orbitocranial zygomatic approach to middle cranial fossa [cavernous sinus and carotid artery, clivus, basilar artery or [...]