Neurosurgery Coding Alert

Hint: Laterality does not matter but be sure to track the number of attempts.

When your neurosurgeon performs a subdural tap in an infant as a diagnostic, stabilizing, or life-saving procedure, don't focus on the intent of the tap but instead keep a count of the number of subsequent taps your surgeon performs to recoup all your earned reimbursement. "Subdural drainage in infants may require a series of percutaneous drainage taps to manage reaccumulation of the subdural fluid," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Use the op note that follows to guide your subdural tap coding:

Operative note: "The child was placed in a supine position and secured in an immobilizer. All appropriate monitoring, ancillary personnel, and resuscitation equipment were confirmed. Small area of hair was clipped or shaved around the target site of the tap. The site of the tap was identified by locating the junction of the coronal and sagittal sutures where the coronal suture forms the lateral margin of the anterior fontanelle such that the puncture will be done in the most lateral aspect of the anterior fontanelle.

Using strict aseptic techniques, a subdural needle, 18 gauge, 1.5 inch spinal needle, was inserted at an angle of 90 degrees to the transverse plane of the skull through the stretched skin over the lateral margin of the anterior fontanelle. Care was taken to avoid the sagittal sinus. The needle was secured in the hand with heel of the hand resting against the child's head. The needle was then slowly advanced through the skin until about 5 to 10 mm to reach the subdural space. The stylet was removed and the needle was clamped at the skin with a hemostat.

There was a spontaneous drainage of fluid and a total of about 40 ml of fluid was drained until the fontanelle became scaphoid. The needle was then removed and a gentle pressure dressing was applied to the puncture site. The fluid was sent for laboratory analysis and histopathological examination."

Keep A Count on All Taps

In this case, it is clear that your surgeon is performing a subdural tap through the anterior fontanelle. You will however look further in the operative note to determine if any similar taps have been done for the patient in the past. In this case, it is the first ever attempt your surgeon makes at the subdural tap, you report this as 61000 (Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; initial). For any subsequent taps, you report code 61001 (Subdural tap through fontanelle, or suture, infant, unilateral or bilateral; subsequent taps).

Note: You use the same codes for any drainage your surgeon does in either the fontanelles or sutures. Also you report the same codes irrespective of whether the drainage is unilateral or bilateral.

"Since the fontanelles do not contain bone, percutaneous access to the subdural space is easiest through fontanelles. However, the skull is also quite thin in early development, offering the option of going through the skull as well. The procedure is coded the same, regardless of the entry point," says Przybylski.