Coding for Endoscopic Skull Base Procedures

Members of the American Rhinologic Society perform various procedures to surgically treat pathology of the skull (cranial) base.  Over the past two decades, the use of endoscopic surgical techniques has supplanted or supplemented many traditional “open” procedures involving facial incisions and surgery involving direct visualization and microsurgical techniques. Despite their widespread use, many of these endoscopic skull (cranial) base approaches, ancillary procedures required for access, resection methods and reconstruction techniques lack specific CPT codes. Additionally, Payers and Insurance Providers have variable guidelines, contracts and requirements for reimbursement. Coding in skull base surgery is, therefore, complex.

Personalized approaches are necessary in skull base surgery as lesions requiring surgery are highly diverse with respect to pathology, location and involvement of surrounding structures.  Surgery may entail external approaches, endoscopic approaches or a combination of the two. Reconstruction may require free grafts, local/ loco-regional flaps, free tissue transfer or in some cases, none.  Additionally, procedures may be performed in conjunction with team surgeons, co-surgeons, assistant surgeons and reconstructive surgeons. Procedures involving the endoscope also require a wide variation in time, effort, risk, and surgical expertise – no different from those procedures involving traditional open approaches and techniques. Each situation should be scrutinized on a case by case basis. 

The American Rhinologic Society recommends that coding should be guided by the spirit of the CPT Manual and by the specific procedures being performed. Using the endoscope for visualization during skull base surgery does not necessarily change the nature of the surgical goals, nor does it imply that a different procedure is performed under the current description of comparable and historical open codes. Therefore, coding should reflect the effort specifically involved in each component of the overall procedure (approach, resection and reconstruction if appropriate). Coding for these procedures may include listed procedure codes (external codes, endoscopic codes), unlisted procedure codes, co-surgeon codes, assistant codes, reconstructive codes or a combination of those codes.

The American Rhinologic Society has not endorsed any specific guidelines or statements from other professional organizations.