tci E/M Coding Alert - 2023 Issue Q3

You Be the Coder: Report This Headache Case With Ease

Question: A new patient reports to the surgeon with severe headaches that have been happening intermittently for the past three weeks. The surgeon orders a computed tomography (CT), which reveals a supratentorial brain lesion. The next day, the surgeon performs a stereotactic excision via burr hole. The pathology on the lesion was benign. How should I report this encounter? Tennessee Subscriber Answer: For this claim, you’d report: 61750 (Stereotactic biopsy, aspiration, or excision, including burr hole(s), for intracranial lesion) for the excision 70460 (Computed tomography, head or brain; with contrast material(s)) for the CT, if the supervision and...

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