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CSF leak postop pituitary tumor removal

Gloria Posted Mon 24th of September, 2012 19:15:21 PM

Patient developed cerebrospinal fluid leak after 62165 -62(Neuroendoscopy, intracranial with excision of pituitary tumor trans-sphenoidal approach - co-surgeon) was performed, which was repaired on the 10th post operative day. My ENT surgeon provided access and cleaned the sphenoid sinus; the neurosurgeon then packed the sella with fascia and muscle; the ENT then placed a cartilaginous graft and the mucoperiosteal flaps of the septum and rostrum of the sphenoid were then replaced. I believe the code is 31291, is that correct? What modifiers would apply? Is this now a co-surgery (62) or assist (80) and who is the primary surgeon? Also, the global on the 62165 is 90 days. Would Unplanned Return to the OR (-78) apply?

SuperCoder Answered Mon 24th of September, 2012 19:52:05 PM

Hi Gloria,

Very nice to have interpreted the report like this. You yourself has answered all questions.Because the otolaryngologist and neurosurgeon will be performing distinct parts of the same procedure, each coder will append modifier 62 (Two surgeons) to the agreed-upon procedure code and yes Modifier 78 will apply here.

31291-78-62(Pricing modifiers before payment modifiers and location modifiers EXCEPT when global surgery package involved, then report payment modifiers before pricing. Example modifier 78 and 62).

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