Neurosurgery Coding Alert
Take the Right Path for Temporal Lobe Resection
Question: How do we report a temporal lobe resection for uncal herniation with the uncus pressing on the brain stem? Our surgeon has also mentioned in the OR that ‘frontotemporal craniotomy with resection of the right temporal lobe’ was done for a glioblastoma. Please help us with the right codes for these procedures.
Answer: The correct code for removal of the temporal lobe for excision of a glioblastoma as well as for uncal hernation (likely a secondary consequence from the edema associated with the tumor) is 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). The extra removal of temporal lobe “not involved” with the tumor is incidental to the craniotomy for tumor removal. If a significant additional amount of time and work were required to decompress the brainstem from the uncal herniation (the uncus is part of the temporal lobe), you may consider appending the 22 (Increased procedural services) modifier.
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Neurosurgery Coding Alert
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