Basics of Neurosurgery Coding – ICD-10-CM
Neurosurgery diagnoses are mainly coded from:
o Chapter 6 (G00–G99): Diseases of the Nervous System
o Chapter 13 (M00–M99): Musculoskeletal system (spine-related conditions)
o Chapter 19 (S00–T88): Injuries & trauma (head injury, spinal trauma)
• Always identify whether the condition involves:
o Brain
o Spinal cord
o Peripheral nerves
• Laterality (right, left, bilateral) is critical, especially for:
o Brain lesions
o Spinal nerve involvement
• Differentiate acute vs chronic neurosurgical conditions
• Common neurosurgery-related diagnoses:
o Brain tumors (benign vs malignant, primary vs secondary)
o Intracranial hemorrhage
o Hydrocephalus
o Herniated intervertebral discs
o Spinal stenosis
o Traumatic brain injury (TBI)
• Use sequela codes for late effects of brain or spinal injuries
• Identify underlying cause vs manifestation (e.g., tumor causing hydrocephalus)
• In inpatient cases, capture CC/MCC conditions impacting MS-DRGs
• Assign Z codes when applicable (history of brain surgery, devices)
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Basics of Neurosurgery Coding – CPT
• Neurosurgery CPT codes are primarily found in CPT Surgery Section (61000–64999)
• Coding is procedure-driven, based heavily on the operative report
• Key neurosurgical procedure categories:
o Craniotomy / craniectomy
o Brain tumor excision or biopsy
o Burr hole procedures
o Ventricular shunts
o Spine surgeries (laminectomy, discectomy, fusion)
o Peripheral nerve decompression
• Understand approach, intent, and extent of surgery:
o Diagnostic vs therapeutic
o Partial vs total excision
• Global surgical package rules apply (pre-op, intra-op, post-op)
• Common modifiers in neurosurgery:
o -51 Multiple procedures
o -59 / -XS Distinct procedural service
o -62 Co-surgeon
o -80 / -82 Assistant surgeon
o -22 Increased procedural services
• Spine coding requires attention to:
o Number of vertebral levels
o Cervical vs thoracic vs lumbar
o Anterior vs posterior approach
• Many neurosurgery codes are bundled—review NCCI edits carefully
• Imaging guidance, microscopy, and navigation may be separately reportable if documented
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Inpatient Neurosurgery & DRG Considerations
• Neurosurgical procedures often group to high-weight MS-DRGs
• Accurate capture of:
o Principal diagnosis
o Procedure codes
o CC/MCC conditions
• POA indicators are mandatory for inpatient claims
• Clinical documentation integrity (CDI) is critical in neurosurgery cases
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Common Neurosurgery Coding Pitfalls
• Missing documentation of levels operated
• Incorrect laterality assignment
• Unbundling procedures incorrectly
• Not applying correct global period rules
• Ignoring NCCI bundling edits
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