Neurosurgery Coding Alert

Question: How can we report for re-do craniotomy? Our surgeon had to re-resect a tumor done in a previous craniotomy. Can we report it with the regular craniotomy codes depending upon the type of craniotomy done and append modifier for unplanned return to the operating room?Alaska SubscriberAnswer: Reporting the re-exploration depends both on the timing and the reason. If the re-exploration is performed within the global period of the original craniotomy as a consequence of a postoperative complication, the code for the type of complication would be reported with the 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period...) modifier. If the re-exploration was performed as a part of a planned staged resection of the tumor, the code would be repeated with the 58 (Staged or related procedure or service by [...]