Neurosurgery Coding Alert

Coding for a repair of dura for cerebral spinal fluid (CSF) leak (61618 or 61619) in the wake of skull base surgery (61592 and 61608) for a brain tumor removal can be tricky. This is because of the need to decide if the repair is technically related or unrelated to the initial surgery.

An incorrect determination can cost a neurosurgery practice considerable amounts of otherwise easily attainable reimbursement. With a proper understanding of when to use secondary repair codes, when a postoperative complication is related or unrelated, and tips for diagnosis coding and documentation, coders will be armed with the necessary reimbursement tools.

Normal Closure or Secondary Repair?

Some neurosurgery coders believe that the secondary repair codes should be used whenever a skull base surgery is performed. This is improper coding because the codes for the primary or definitive procedure do not specifically list closure. However, according to Medicare guidelines, a standard closure is included in the definitive procedure. A secondary repair code should only be used when the specific circumstances described in the definitions are met.

For example, a patient has skull base surgery. It consists of an infratemporal approach with a left frontotemporal craniotomy coded as 61592 (orbitocranial zygomatic approach to middle cranial fossa [cavernous sinus and carotid artery, clivus, basilar artery or petrous apex] including osteotomy of zygoma, craniotomy, extra- or intradural elevation of temporal lobe). The definitive procedure consists of an orbitotomy, the complete removal of the intradural portion of the tumor, and closure is coded as 61608 (resection or excision of neoplastic, vascular or infectious lesion of parasellar area, cavernous sinus, clivus or midline skull base; intradural, including dural repair, with or without graft). This is a standard skull base operation.

The repair and reconstruction codes for these surgeries, 61618-61619 (see definitions below) are designed to be used when the secondary repair of the dura occurs at a different operative session, says Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.

These codes are not meant for a normal closure and will be denied.

Definitions: 61618 secondary repair of dura for CSF leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft [e.g., pericranium, fascia, tensor fascior lata, adipose tissue, homologous or synthetic grafts]; and 61619 ... by local or regionalized vascularized pedicle flap or myocutaneous flap [including galea, temporalis, frontalis or occipitalis muscle].

Related or Unrelated?

If the patient needs to be returned to the operating room during the 90-day global period for secondary repairs to the dura, 61618 or 61619 should [...]