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Question: Encounter notes indicate that the surgeon performed craniotomy for a patient with a malformation due to type II Arnold-Chiari syndrome without spina bifida or hydrocephalus. They removed a portion of the occipital bone at the back of the skull to relieve pressure on the brain stem and spinal cord. The surgeon then expanded the dura by suturing a dural graft in place. How should I code this encounter?

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Answer: For this encounter, report 61343 (Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (eg, Arnold- Chiari malformation)) for the craniotomy. Since the dural graft is mentioned in the 61343 descriptor, you shouldn鈥檛 submit an additional code for the graft placement. Also, append Q07.00 (Arnold-Chiari syndrome without spina bifida or hydrocephalus) appended to 61343 to represent the patient鈥檚 condition.

Arnold-Chiari alert: There are several diagnosis code options for Arnold-Chiari malformation, type II. In addition to Q07.00, you might have also chosen one of the following codes for a type II malformation:

• Q07.01 (Arnold-Chiari syndrome with spina bifida)
• Q07.02 (Arnold-Chiari syndrome with hydrocephalus)
• Q07.03 (Arnold-Chiari syndrome with spina bifida and hydrocephalus)

Arnold-Chiari alert 2: The Q07.- (Arnold-Chiari syndrome) codes are for type II Arnold-Chari malformations as well as type I malformations 鈥� even though there are differences in the conditions. According to Mayo Clinic, 鈥渢ype I Chiari malformation symptoms and signs can show up in infants, children, teens or adults. Type II Chiari malformation is associated with spina bifida and is present at birth.鈥�

If however, the notes mention type III Arnold-Chari malformation, you鈥檒l choose a code from the Q01.- (Encephalocele) set. When it鈥檚 indicated that the patient has a type IV malformation, you鈥檒l choose a code from the Q04.8 (Other specified congenital malformations of brain) set.