Neurosurgery Coding Alert

Question: A neurosurgeon performed a bilateral craniectomy with fenestration of septum pellucidum and intraventricular cysts for multiloculated hydrocephalus. Per the operative report: ... an incision was made in the left frontal region. Dissection was carried down to bone below. The craniectomy was fashioned with a combination of Midas Rex drill and Kerrison rongeur. The dura was then incised and an introducer was placed in the left lateral ventricle followed by the endoscope. The endoscope was used to identify the foramen of Monro, and an aperture was made into the cyst that was in the third ventricle. Our attention was turned to the septum, and an aperture was made using a Bugbee wire and coagulation in the right lateral ventricle. Attention was turned to the opposite side where a similar procedure was performed. How should this be reported?

Delaware Subscriber  
Answer: From the information given, this procedure should be coded 62200-RT (ventriculocisternostomy, third ventricle; right side) and 62200-51-LT (... multiple procedures; left side) to indicate that separate craniotom-ies and fenestration procedures were performed on the left and right sides of the brain. Modifiers -LT and -RT are less confusing to many payers in this instance than modifier -50 (bilateral procedure). Because modifier -51 is attached to the second procedure code, payment for the left side may be reduced by as much as 50 percent.
 
For the diagnoses, include 348.0 (cerebral cysts) for the ventricular cysts and 331.4 (obstructive hydrocephalus) for the hydrocephalus.
 
The payer may initially reject the claim or request additional information, so keep documentation, including the operative report, ready, and be prepared to appeal.