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Neurosurgery Coding Alert

READER QUESTIONS:

Pituitary Resection Calls for Co-Surgeons

Published on Fri Aug 12, 2005

Question: Our surgeon is scheduled to perform endoscopic resection of a pituitary tumor. An ENT surgeon will perform the approach. How should we report this procedure? Will the ENT surgeon report the approach separately using his own codes?


Michigan Subscriber
Answer: In this case, both surgeons should report 62165 (Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach) with modifier 62 (Two surgeons) appended. The ENT surgeon should not report the approach separately using his own codes, because the approach is included in 62165.

Each surgeon will perform a distinct portion of a single identifiable procedure (the ENT will perform the approach, the neurosurgeon will perform the endoscopic resection and often, the closure), and each surgeon should dictate an operative note outlining his portion of the surgery.

Learn more: For complete information on reporting co-surgeries, see "Important Steps for Co-Surgery Reimbursement," Neurosurgery Coding Alert, April 2004.
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