Coding correctly is easy – when you know these keys.
Your anesthesiologist is called in to provide services during surgery to treat a benign central tumor. But neurosurgeons can operate on numerous benign tumors – pineal gland tumors, benign pituitary tumors, craniopharyngiomas, and carotid body tumors. As confusing as it might seem at the outset, breathe easier in knowing each of these benign tumors has its own definitive codes.
Starting Point: Pituitary Tumor vs. Craniopharyngioma
Most tumors in the pituitary are benign. These tumors appear as an abnormal growth in the pituitary gland.
Watch the size: The diagnosis of a pituitary mass may be an incidental finding on an MRI or CT scan if the pituitary tumor is small and does not produce any hormones. Pituitary tumors may produce one or more hormones in excess and lead to symptoms like gigantism, Cushing’s syndrome, galactorrhea, decreased sexual function, and others. Large pituitary tumors may cause mass effects like headache, nausea and vomiting, double vision, and dropping eyelids.
However, similar symptoms may be caused by a craniopharyngioma which is a benign tumor arising from a craniopharyngeal duct. Such tumors can often grow to more than 3 cm in size and press upon the pituitary stalk or the pituitary gland. This may lead to partial or complete deficiency of one or more pituitaryhormones.
ICD-10-CM offers specific codes: For benign tumors of the pituitary gland, you submit ICD-10-CM code D35.2 (Benign neoplasm of pituitary gland). However, when the physician documents craniopharyngioma, you report ICD-10-CM code D35.3 (Benign neoplasm of craniopharyngeal duct) instead.
Target Single Code for Benign Pineal Neoplasms
When the neurosurgeon diagnoses a benign tumor of the pineal gland, submit ICD-10 code D35.4 (Benign neoplasm of pineal gland).
Know the glands: The pineal gland is a structure in the brain that produces a hormone called melatonin which plays an important role in controlling sleep. Tumors in the pineal gland may grow to compress the surrounding structures. Depending upon the structures that the tumorous mass compresses, the patient may experience headaches, vomiting, visual disturbances, balance and coordination problems, and hormonal imbalances.
Think of Paragangliomas as Benign
The neurosurgeon may document a diagnosis of paraganglioma in a patient with a painless mass in the neck. Also called a carotid body tumor, the carotid paragangliomas though rare, are the commonest head and neck paragangliomas. These benign tumors arise from embryonic neuronal cells. Sometimes, these tumors may present with symptoms of cranial nerve involvement, most commonly the vagus nerve.
For a diagnosis of carotid paraganglioma, you report code D35.5 (Benign neoplasm of carotid body). Most paragangliomas are benign.