How To Use CPT Code 62165

CPT 62165 describes a neuroendoscopy procedure that involves the removal of an abnormal growth in the pituitary gland. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 62165?

CPT 62165 is used to describe a neuroendoscopy procedure that involves the removal of a pituitary tumor using a transnasal or trans-sphenoidal approach. This code is specifically for the excision of the tumor and does not include any additional procedures that may be performed during the surgery.

2. Official Description

The official description of CPT code 62165 is: ‘Neuroendoscopy, intracranial; with excision of pituitary tumor, transnasal or trans-sphenoidal approach.’

3. Procedure

1. The patient is appropriately prepped and anesthetized, and their head is placed in a head holder to ensure stability during the procedure.
2. The provider marks the location of the abdominal incision for potential reconstruction and prevention of cerebrospinal fluid leakage.
3. Using a neuroendoscope, the provider accesses the pituitary gland through either a transnasal or trans-sphenoidal approach.
4. A small incision is made, and the provider navigates through the nasal passage or sphenoid bone to reach the sella turcica, where the pituitary gland is located.
5. The provider removes the bone of the sella turcica to expose the dura and locates the tumor.
6. Using a combination of curettage and suction, the provider excises the tumor and sends samples for laboratory testing.
7. The provider uses the neuroendoscope to ensure complete removal of the tumor and to identify any remaining tumor remnants.
8. Hemostasis is achieved, and the sella is irrigated.
9. The provider may use a fat or muscle graft harvested from the abdomen to aid in the reconstruction of the sella turcica and prevent cerebrospinal fluid leakage.
10. The dural opening is closed, and all instrumentation is removed.
11. The area may be packed with sterile gauze or a gauze sponge may be placed at the base of the nose.

4. Qualifying circumstances

CPT 62165 is performed on patients with pituitary tumors that require surgical excision. The procedure is typically performed by a neurosurgeon or an otolaryngologist who specializes in endoscopic skull base surgery. The patient must meet the criteria for surgery, which is determined through a thorough evaluation and diagnostic testing.

5. When to use CPT code 62165

CPT code 62165 should be used when a neuroendoscopy procedure is performed to excise a pituitary tumor using a transnasal or trans-sphenoidal approach. This code should not be used for other types of neuroendoscopy procedures or for the excision of tumors in different locations.

6. Documentation requirements

To support a claim for CPT 62165, the provider must document the following information:

• Patient’s diagnosis and the need for surgical excision of the pituitary tumor
• Approach used (transnasal or trans-sphenoidal)
• Date of the procedure
• Details of the procedure, including any additional procedures performed
• Extent of tumor excision
• Use of any grafts for reconstruction
• Complications, if any
• Signature of the performing provider

7. Billing guidelines

When billing for CPT 62165, ensure that the procedure meets the criteria for surgical excision of a pituitary tumor using a transnasal or trans-sphenoidal approach. It is important to accurately document the details of the procedure and any additional procedures performed. CPT code 62165 should not be reported with other codes unless additional procedures are performed that are separately reportable.

8. Historical information

CPT code 62165 was added to the Current Procedural Terminology system on January 1, 2003. The code has not undergone any updates since its addition. In 2017, it was added to the Inpatient Only (IPO) list for Medicare billing purposes.

9. Examples

1. A neurosurgeon performing a transnasal neuroendoscopy to excise a pituitary tumor in a patient with acromegaly.
2. An otolaryngologist using a trans-sphenoidal approach to remove a pituitary tumor in a patient with Cushing’s disease.
3. A neurosurgeon performing a transnasal neuroendoscopy to excise a pituitary tumor in a patient with prolactinoma.
4. An otolaryngologist using a trans-sphenoidal approach to remove a pituitary tumor in a patient with non-functioning adenoma.
5. A neurosurgeon performing a transnasal neuroendoscopy to excise a pituitary tumor in a patient with Rathke’s cleft cyst.
6. An otolaryngologist using a trans-sphenoidal approach to remove a pituitary tumor in a patient with growth hormone deficiency.