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AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 2; Ask the Editor

Excision of Pituitary Macroadenoma within Cavernous Sinus

The patient was admitted for surgical excision of a pituitary macroadenoma within the cavernous sinus. A left pterional incision was made and dissection was carried down to the dura and zygomatic osteotomy, which allowed excellent exposure of the anterior middle fossa. Attention was then turned to the anterior middle fossa and the lateral cavernous sinus. There was a small area where tumor had eroded through the dura and this area was quite boggy consistent with cavernous sinus involvement. The small tumor breach allowed the provider to enter the cavernous sinus, which was widely opened. The tumor cavity was entered and the tumor was removed with suction and with ring curettes. What is the appropriate ICD-10-PCS code for excision of the pituitary macroadenoma within the cavernous sinus? ...

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