Neurosurgery Coding Alert

Question: Our surgeon routinely performs 61343 to repair Chiari malformation. Now we have a case where he completed that procedure and also resected an additional cyst in the cerebellar tonsil during the Chiari malformation decompression. Can we code both procedures? If so, do we append a modifier? New Mexico Subscriber Answer: You should consider looking at craniectomy procedures represented by 61343 (Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft [e.g., Arnold-Chiari malformation) and 61524 (Craniectomy, infratentorial or posterior fossa; for excision or fenestration of cyst). The Correct Coding Initiative (CCI) edits currently do not bundle these codes, so you should be able to report both on the claim with sufficient documentation. If resection of the cyst was distinct and separate from the work required to decompress the Chiari malformation, you can report both codes. Tricky: Not sure whether to append modifier [...]