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Patient returns to OR following a right-sided decompressive hemicraniectomy

Debra Posted Tue 10th of March, 2020 16:55:25 PM
Patient returns to OR three days following a right-sided decompressive hemicraniectomy for worsening neurological function and transtentorial brain herniation. Surgeon performed an opening of the previous right-sided hemicraniectomy scalp flap and a right-sided frontal and temporal lobectomy. A frontal lobectomy was performed all the way to the falx cerebri and the anterior cranial fossa. Then attention to the right temporal lobe where a partial temporal lobectomy was performed all the way down to the edge of the tentorium. Placement of the bone flap into the subcutaneous tissue of the abdomen was performed on the first surgery. Question: What would be the appropriate CPT procedure code to use? Would either CPT code 61537-52 or 61323-52 be appropriate in this situation? Please provide any input you may have.
SuperCoder Answered Wed 11th of March, 2020 05:22:57 AM

Hi Debra,

 

CPT code 61323 with 52 modifier would be the appropriate CPT code to use for decompressive craniectomy with lobectomy performed for removal of intracranial pressure (ICP).  CPT code 61537 would not be appropriate since this code is specific to craniectomy with lobectomy performed at temporal lobe only where as procedure was performed at frontal lobe as well. Therefore, CPT code 61323 with 52 modifier would be the most appropriate code as per the provided documentation.

 

Hope provided information would be helpful!

 

Thanks!

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