Sara Posted Mon 05th of November, 2012 18:35:30 PM
A cerebrospinal fluid repair by my surgeon done during a radical mastoidectomy performed by an ENT surgeon. My surgeon did not open or close. Is there an appropriate code, if so do I need to use modifier 52 since my surgeon didn't open or close?
SuperCoder Answered Mon 05th of November, 2012 18:58:13 PM
Was the leak due to the surgery?
Jen Godreau, CPC, CPMA, CPEDC
SuperCoder Answered Tue 06th of November, 2012 11:55:55 AM
For co-surgeries or when two surgeons work together and perform two parts of different CPT codes, each surgeon reports the procedure he performed.
Regarding your two code choices, 62100 requires a craniotomy. If your surgeon opened the skulled and performed the CSF repair but did not do the close, use modifier 52 on 62100.
If the repair was done due to the mastoidectomy, the repair is included in the mastoidectomy as it is a result of the operation.
Code 61618 is not appropriate. This is used after a skull based surgery was performed at a previous encounter. Neither criteria is met in this scenario.