Neurosurgery Coding Alert

Question: A new patient with normal-pressure hydrocephalus reports to the surgeon. After an office evaluation and management (E/M) service that lasts 65 minutes, the surgeon decides to perform subtemporal cranial decompression. How should I report this encounter?

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Answer: For this patient, report:

• 61340 (Subtemporal cranial decompression (pseudotumor cerebri, slit ventricle syndrome) for the decompression
• 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded.) for the E/M
• Modifier 57 (Decision for surgery) appended to 99205 to show that the E/M was performed separately and led to the decision for surgery
• G91.2 ((Idiopathic) normal pressure hydrocephalus) appended to 61340 and 99205 to indicate the patient’s hydrocephalus

Exception: According to CPT^®, “for decompressive craniotomy or craniectomy for intracranial hypertension, without hematoma evacuation, see 61322 [Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy], 61323 [… with lobectomy].)”