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Skull Base Surgery

  1. Default Skull Base Surgery
    Medical Coding Books
    I'm hoping this will be an easy question, without need of an op report.

    Pt had previously had a "Resection or excision of neoplastic, vascular or infectious lesion of base of posterior...", reported as CPT 61616/61597, performed. 3mos later, pt has an injury and comes in for the rupture of a suture line along the posterior fossa. Per CPT coding guidelines it has been determined that CPT 61618 is being appropriately reported for this repair procedure. The Neurosurgeon insists that he should also be reporting CPT 61597, because he performed an extradural exposure of the craniovertebral junction in order to microsurgically repair the cerebrospinal fluid leak along the posterior fossa dura and craniovertebral junction.

    Is the Neurosurgeon correct?? Based on the CPT guidelines found in the CPT Book, under "Surgery of Skull Base", the agreed upon code for repair 61618 is listed under the Category "Repair and/or Reconstruction of Surgical Defects of Skull Base"; therefore, should an appropriate "Approach" code also be reported, such as 61597??

    Any help is appreciated.

  2. #2
    Milwaukee WI
    Default Approach is excluded
    Approach is excluded, so, YES, you can bill these two codes together.

    F Tessa Bartels, CPC, CEMC

  3. Default Thank you
    F Tessa Bartels, CPC, CEMC, I would like to thank you for your help.

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