Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon performed a suboccipital craniectomy, during which they took sections of two cranial nerves. The patient suffers from trigeminal neuralgia. I reported 61458 x 2 and received a denial. What did I do wrong?

Kentucky Subscriber

Answer: You shouldn’t have reported 61458 (Craniectomy, suboccipital; for exploration or decompression of cranial nerves), and you certainly shouldn’t have reported 61458 x 2. This code is for exploration or decompression of cranial nerves, and you want a code that reflects the sections your surgeon performed during the surgery.

Do this: On appeal, report 61460 (… for section of 1 or more cranial nerves) with G50.0 (Trigeminal neuralgia) appended. As the descriptor indicates, 61460 is for one or more cranial nerves, so don’t report it twice.