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Brain lesion biopsy

Barbara Posted Mon 02nd of March, 2015 12:34:36 PM

Can you help me with which CPT procedure codes I should use for a "left sided temporo-occipital extracalvarial biopsying, as well as a mini craniotomy and obtaining of dural biopsy of lymphoma using a Medtronic Stealth neuro navigation. Condensed report follows:

An incision was marked 3-4 inches posterior to the left ear. Marked out the transverse sinus with the Stealth navigation and made an incision centering over the extracalvarial disease as well as the dural disease staying superior to the transverse sinus. After timeout was done a small incision was made identifying some abnormal tissue underneath the galea. This was sent for frozen section. Also performed a small craniotomy with a large acorn bit, was able to use a curet to free up the dural edges and was a able to take approx. 0.5 x 0.5 cm square dural biopsy which was sent to pathology and came back consistent with lymphoid tissue. Once satisfied with the amount of sample that were taken including the extracalvarial portion, the bony portion as well as the dural portion, A small piece of gelfoam was placed over the dura, along with some thrombin Gelforam over the area to ensure that there was no bleeding. A small cranial plate was fixated with 3 screws.

The coder used CPT codes 20240 and 64999 which is not passing thru the edits. I think a code or codes along the line of 61140 and 61304 may be appropriate, but don't really know, as I have never coded neurosurgery before.

SuperCoder Answered Tue 03rd of March, 2015 07:13:52 AM

Hi Cilia,
Thank you for the query.
The code for extracalvarial biopsy should be CPT 20240 whereas for dural biopsy CPT 61304 seems appropriate as craniotomy was done rather than the burr hole surgery.

Hope it helps you.

Thank you

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