Approach to Pituitary Tumor

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May 26, 2016

Question:
I am with Otolaryngology and one of our Physicians has done a case with a Neurosurgeon. I need some advice regarding coding. They did a transsphenoidal pituitary tumor together where our physician opened and assisted the neurosurgeon. The neurosurgeon did 61548 and our physician said he did 30520, 31287-50, 31240-LT, and 30930. Please advise on the best way to bill.

Answer:
The approach (including septoplasty, sphenoidotomy, etc.) to the pituitary tumor and the tumor resection is included in 61548. When ENT does the approach and neurosurgery takes out the tumor, this is considered co-surgery and both surgeons report the same CPT code (61548) with modifier 62 (two surgeons). Therefore, the best way to code the procedure is for each surgeon to report 61548-62. It would be considered “unbundling” to report separate codes for the approach including the septoplasty and sinus surgery. If the procedure is performed endoscopically, then both surgeons report 62165-62.

*This response is based on the best information available as of 05/26/16.