Neurosurgery Coding Alert

Question: Our surgeon did a cerebrospinal fluid repair during a radical mastoidectomy performed by an ENT surgeon. Our surgeon however did not close. Do we report this with 62100 (Craniotomy for repair of dural/cerebrospinal fluid leak, including surgery for rhinorrhea/otorrhea) or 61618 (Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft [e.g., pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts])? Alaska Subscriber Answer: More details regarding the circumstances would be needed to precisely answer the question. In general, anything that is opened in a procedure, even if unintentionally, is expected to be closed. The degree of involvement of your surgeon including whether a craniotomy was performed or additional bone work was required to close the CSF leak will influence the coding recommendation. Depending on the specific circumstances, this may be reported with [...]