To report the reduction services for a craniomegalic skull correctly, you’ll need to go through the op note to identify any cranioplasty or craniotomy work your surgeon did. Plus knowing when to report any bone grafts will also be helpful. Follow this advice to accurately capture all craniomegalic skull reduction services.
Confirm the Cranioplasty
When reducing a craniomegalic skull, your surgeon may simply manipulate and maneuver the bones in order to appropriately position them. In this case, your surgeon neither does a cranioplasty nor uses any bone grafts for repair. If your op note specifies no cranioplasty or bone grafts, report 62115 (Reduction of craniomegalic skull [eg, treated hydrocephalus]; not requiring bone grafts or cranioplasty) for the reduction your surgeon performed. Here your surgeon basically tries to improve the skull symmetry by remolding the skull bones. “These uncommon procedures are typically performed in children who had late treatment of hydrocephalus, resulting in disproportionate size of the head,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.
Get all the coding info you need to increase your accuracy, decrease your compliance risk and work faster from one jam-packed solution that links smart code search with thousands of documents all on 1 easy-view dashboard. Click here to buy Coding Tools.
However, to replace a portion of the skull, the surgeon may need to perform a cranioplasty during reduction of a craniomegalic skull, using either bone tissue or synthetic materials. For simple cranioplasties during the procedure, you would report code 62116 (Reduction of craniomegalic skull [eg, treated hydrocephalus]; with simple cranioplasty).
Example: If the operative note suggests that your surgeon used synthetic...
- Free updates on CPT, ICD-9, HCPCS, Medicare, NCCI edits, and ICD-10.
- Discounts on 3rd party offers