Neurosurgery Coding Alert

Question: How should I report resection of a pineal tumor using microdissection? The surgeon specified a supracerebellar infratentorial approach.

California Subscriber Answer: You should report 61518 (Craniectomy for excision of brain tumor, infratentorial or posterior fossa; except meningioma, cerebellopontine angle tumor, or midline tumor at base of skull) for the resection and +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]) for the microdissection.

In this case, you should have no problem receiving reimbursement for use of the operating microscope. Both CPT and Medicare guidelines allow for separate payment for 69990 with 61518. This will not always be so: CMS guidelines for 69990 differ from CPT's instructions, and this can cause real confusion for payers.

Medicare uses the more stringent restrictions. The Medicare Carriers Manual, section 15055, limits separate payment for 69990 to procedures 61304-61546, 61550-61711, 62010-62100, 63081-63308, 63704-63710, 64831, 64834-64836, 64840-64858, 64861-64870, 64885-64898 and 64905-64907. For all other procedures, Medicare considers the operating microscope unreimbursable.

CPT, in contrast, specifies 69990 as an integral component of far fewer codes, including (among others) excision of pituitary tumor 61548, diskectomy 63075-63078, internal neurolysis 64727, and sympathectomy procedures 64820-64823.

The lesson here is that you should know your payer (and its rules) before reporting 69990: If you neglect to report 69990 when the payer allows it, you're forfeiting payment, but if you're reporting 69990 when you shouldn't, you could face an audit.