Meningoencephalocele and CSF leak repair

The physician endoscopically repairs a meningoencephalocele that was herniating down into the nasal cavity. Endoscopic coblation was used to repair the meningoencephalocele that was leaking CSF fluid. Alloderm grafts were applied intracranial and extracranial. The right middle turbinate was resected and used as a bone graft for the skull base defect. The physician's code selection is 64999 (Endoscopic repair of encephalocele, skull vault, including cranioplasty), 31290,
31276, 31255, 31255, 31256, 61782, 15335, 31240, and 30210. However, I am not sure if the coblation should be billed separately (64999) because it seems to me that it is included in 31290, correct? If medically necessary, can the other sinus procedures be billed along with the CSF leak repair? I also captured 31267 instead of 31256 because is see that tissue was removed from the maxillary sinus,
correct? Last, but not lease, for 31240: based on the documentation, the turbinate was resected for no other reason than for repairing the skull defect. In terms of harvesting bone grafts, is this considered to be the "same incision site"? OR should it be coded as 20900 instead? Or should that be included in 31290? Is the Alloderm graft included in 31290 as well?

re: Meningoencephalocele and CSF leak repair

There is no CPT® code for this procedure; therefore, you must use an unlisted code (64999) to describe all procedures performed through the nose including harvest of graft material. The Alloderm is not separately reported since there is no "skin" replacement happening in this procedure.

Kim Pollock, RN, MBA, CPC
Consultant
KarenZupko & Associates, Inc.
www.karenzupko.com

re: Meningoencephalocele and CSF leak repair

All of the sinus procedures performed through the nose are included in 64999 even if the documentation shows medical necessity?

Thanks,

Chastity Nault, CPC

re: Meningoencephalocele and CSF leak repair

Your note says the purpose of the procedure is to repair a meningoencephalocele and CSF leak - so yes, one unlisted code (64999).

Kim Pollock, RN, MBA, CPC
KarenZupko & Associates, Inc.
www.karenzupko.com

re: Meningoencephalocele and CSF leak repair

Why not 62121? You are repairing an encephalocele +/- CSF leak including a cranioplasty/skull base repair, just via the nose and using an endoscope vs a craniotomy. Also, do you add 61618 for CSF leak repair with a free mucosal graft or is that included in 62121 or 64999 if used?
Thank you very much.

re: Meningoencephalocele and CSF leak repair

[Why not 62121? You are repairing an encephalocele +/- CSF leak including a cranioplasty/skull base repair, just via the nose and using an endoscope vs a craniotomy. Also, do you add 61618 for CSF leak repair with a free mucosal graft or is that included in 62121 or 64999 if used?
Thank you very much.
]

Because 62121 is an open code (Craniotomy) and this was done via transnasal endoscopic. 61618 is for a secondary repair of the dura following a craniotomy or skull base procedure. In this case it is included in the primary repair. However, you are allowed to code for the free graft if it was documented and performed.

re: Meningoencephalocele and CSF leak repair

What would be the most appropriate code for the turbinate free mucosal graft?
thank you.

re: Meningoencephalocele and CSF leak repair

If you are using a skull base definitive procedure and are wanting to code an extensive repair of the dura, then I would suggest looking at codes: (15732, 15756-15758). Otherwise it is most likely included in the primary procedure.

re: Meningoencephalocele and CSF leak repair

Our repairs are essentially the same as described above in principle. A purely endoscopic approach with a multi-layer repair of the dural and bony skull base defects. Typically we use Duragen intracranially/extradurally, followed by bone or cartilage from the septum, and either a free mucosal graft (turbinate) or a pedicled nasoseptal flap. This technique is used for CSF leak repairs, tumor removal (anterior skull base and pituitary), meningoencephaloceles, etc. I'll just use the 64999 to include it in the repair. for transphenoidal endoscopic approaches we have been using 62165-62. is this correct?