The Coding Challenge
Question: A 4-month-old boy presented to the outpatient clinic with an atypical head shape. After a physical examination and preoperative scanning images, a diagnosis of sagittal synostosis (scaphocephaly) was confirmed. A neurosurgeon and plastic surgeon worked as co-surgeons to treat the condition using an endoscopic-assisted craniectomy technique. A week following surgery, the child will be fitted with a custom-made cranial orthosis to help with reshaping. Assign for ICD-10-CM and CPT for the neurosurgeon.
A. Q75.0, 61550
B. Q75.01, 61550-62
C. Q75.001, 61558-62
D. Q75.01, 61552
B. Q75.01, 61550-62
Sagittal Synostosis (Scaphocephaly)
The patient is diagnosed with sagittal synostosis, also called sagittal craniosynostosis. Sagittal synostosis is the most common type of craniosynostosis. It occurs when the sagittal suture fuses prematurely and results in the elongation of the baby’s head in a narrow manner, known as scaphocephaly.
In other words, the head shape is long from front to back and narrow from side to side. The forehead often becomes tall and pushes forward (frontal bossing), and the back of the skull may become pointed or narrowed.
ICD-10-CM Coding for Craniosynostosis
Before October 1, 2023, craniosynostosis was reported with ICD-10-CM code Q75.0. Now, however, craniosynostosis is reported with one of several new codes based on the specific type and laterality.
Locate and Verify
To locate the correct code in the Index, go to Craniosynostosis/sagittal, Q75.01. In the Tabular, we can verify the correct code as:
Q75.01, Sagittal craniosynostosis
CPT Coding for Endoscopic-Assisted Craniectomy
The surgery performed was an endoscopic-assisted craniectomy. The affected suture was the sagittal suture, which is a single suture. In CPT, craniectomy procedures for craniosynostosis involve the removal of bone from specific skull locations and are reported with codes 61550 or 61552, depending on the number of sutures affected.
- 61550 Craniectomy for craniosynostosis; single cranial suture
- 61552 Craniectomy for craniosynostosis; multiple cranial sutures
Note: A craniectomy is similar to a craniotomy. However, the two procedures vary.
Locate and Verify
In the CPT Codebook Index, look up Craniectomy/Craniosynostosis/Single Suture, 61550. When we go to this code in the Surgical Procedures on the Nervous System section, we can verify the correct code as:
61550, Craniectomy for craniosynostosis; single cranial suture
Modifier 62: The surgery is performed by a neurosurgeon and a plastic surgeon, each participating in their respective roles. Therefore, when coding for the procedure, the medical coder for each surgeon should append modifier 62 to the CPT code, making it 61550-62. Each surgeon would write an operative report explaining their part in the procedure.
Cranial helmet: Approximately one to two weeks following surgery, the baby will be placed in a custom-made cranial helmet to aid in reshaping the head. This will be worn for several months. When that occurs, a HCPCS supply code for the helmet would be reported with S1040, Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, including fitting and adjustment(s).
Short Video on Sagittal Craniosynostosis and Endoscopic-Assisted Craniectomy
A, C, and D are incorrect.
A. Q75.0, 61550. ICD-10-CM code Q75.0 is an invalid code for FY 2024. CPT code 61550 is correct, but it is missing modifier 62.
C. Q75.001, 61558-62. ICD-10-CM code Q75.001 refers to Craniosynostosis unspecified, unilateral. CPT code 61558 refers to Extensive craniectomy for multiple cranial suture craniosynostosis (e.g., cloverleaf skull); not requiring bone grafts.
D. Q75.01, 61552. CPT code 61552 refers to Craniectomy for craniosynostosis; multiple cranial sutures. It is also missing modifier 62.