Neurosurgery Coding Alert

Question: After a level five outpatient evaluation and management (E/M) service for an established patient, the surgeon decided to perform a bone flap craniotomy the following morning. Notes indicate the procedure was supratentorial. What is the correct coding for this claim?

Idaho Subscriber

Answer: First, we’ll address the easy part: For the E/M service, you’ll report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) with modifier 57 (Decision for surgery) attached. Remember, you’ll use modifier 57 to separate significantly identifiable E/Ms from surgeries when the global period for the surgery is 90 days, which it will be (more on that later). If the surgery your provider was about the perform had a 0- or 10-day global period, you’d append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99215.

Next, the surgery. Given the information you have provided, you can narrow down your code choices to this quartet:

• 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma)
• 61512 (… for excision of meningioma, supratentorial)
• 61514 (… for excision of brain abscess, supratentorial)
• 61516 (… for excision or fenestration of cyst, supratentorial)

No matter which of these codes you choose, you’d still opt for modifier 57 on 99215 as they all have 90-day globals when the decision for surgery is made at that E/M visit and the surgery is performed that same day or the following day.

Best bet: Go back and check the notes for any more specific information on the surgeon’s actions during the craniotomy. What the surgeon did during the encounter could lead you to the proper CPT^® code. Also, check the diagnoses for the patient; if notes indicate that they had a cranial cyst, for instance, you might be able to find evidence that 61516 is the right code.

One more thing: If the surgeon implants a chemotherapy agent during the craniotomy (typically when a malignant brain tumor is encountered), report +61517 (Implantation of brain intracavitary chemotherapy agent (List separately in addition to code for primary procedure)) for the service. Remember that +61517 is an add-on code, and you can never report it as a standalone code.