Neurosurgery Coding Alert

Tip: Appropriate modifiers are the best rescue for your claims.

You can confidently report your surgeon's burr hole drainage of subdural or extradural hematomas if you understand when you can append modifiers to codes for these services. Reviewing how to code multiple burr holes and identifying the appropriate sites will also strengthen your reporting of burr hole drainage procedures.

Examine This Case

Read the operative note below for an example how your surgeon may document the burr hole drainage of a subdural hematoma:

"The patient's head was partially shaved and was firmly held in the neutral position using Mayfield head pins. The area was then prepped and draped using an antibiotic solution. A transverse linear incision of around 3 cm in length was made over the frontal and parietal convexities to reflect the scalp over the area of the hematoma. An air powered drill was then used to make a hole around 2 cm in diameter in the skull in the frontal region and another one in the parietal region. The dura was opened with a cruciate incision and the clot was visible. Bipolar cautery was used during the dual opening and to shrink the dural leaflets. The clot was decompressed slowly with close monitoring of the blood pressure and fluid infusions. A Silastic catheter of 2.5 mm outer diameter and 2 mm inner diameter was introduced into the subdural space. Irrigation was done with Hartmann's solution until clear fluid returned. The catheter was then brought out through a stab scalp incision made approximately 2.5 cm posterior to the frontal scalp incision. The scalp incisions were then closed in two layers."

61154 Implies Multiple Burr Holes

In the operative note above, you read that the surgeon made two burr holes, one in the frontal and another in the parietal region. You report these services with code 61154 (Burr hole[s] with evacuation and/or drainage of hematoma, extradural or subdural).

Caveat: You will not report two units of 61154 for this procedure. "Drainage of a single subacute or chronic subdural hematoma is typically accomplished through paired burr holes. However, one should only report 61154 once, even if several holes are used to evacuate the hematoma," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. The code descriptor for 61154 clearly mentions that you may report the code for one or more burr holes that your surgeon makes to drain a hematoma.

On the other hand, your surgeon may be draining multiple small hematomas through multiple burr holes. "The only time when you may consider multiple units of 61154 would be if there are several injuries/bleeds in different parts of the brain, which would require a possible repositioning of the patient or separate incisions. If you are dealing with a single bleed, even if it crosses over to different parts of the brain, it would still be used only once, even with multiple burr holes performed," says Rena Hall, CPC, Kansas City Neurosurgery, North Kansas City, Missouri.

Also, the same code applies for drainage of both subdural and extradural hematomas. These hematomas differ in their location in relation to the dura. The subdural hematoma lies below and the extradural hematoma lies above the dura. "However, since most symptomatic extradural hematomas are treated acutely with craniotomy or craniectomy, the technique of burr hole drainage is most commonly applied to subacute or chronic subdural hematomas," says Przybylski.

Report Any Repeat Procedures

A spontaneous recurrence of a subdural hematoma may further challenge your coding. You should remember that the global period for 61154 starts the day prior to surgery and extends for 90 days postoperatively. If you read that your surgeon had to repeat the drainage of the subdural hematoma in the global period, say six weeks after the initial drainage, you will need to know if you can report another unit of 61154. You may append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period...) to 61154. You will, however, need to confirm in the clinical note if the second hemorrhage was a consequence of the first surgical drainage. "For example, if a recurrent hemorrhage developed as a consequence of removing a subdural catheter, performing a second drainage of the recurrent subdural would be considered related to the original procedure," says Przybylski.

Sometimes, you may need to report the second hemorrhage as an entirely independent procedure, though it occurred in the global period of the first drainage. You may report code 61154 for the second time in such a case.

Do this: Your surgeon will need to document very clearly that the second drainage wasn't related to the initial procedure. In this case, you report 61154 and append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional...).

Spontaneous recurrence of a subdural hematoma often occurs as a consequence of the disease process itself. "The fragility of vascularized tissues along with incomplete cerebral expansion contribute to the development of spontaneous recurrence. In this circumstance, the recurrent drainage should be reported with the 76 modifier," says Przybylski.

Append Modifiers To Boost Payment

When your surgeon makes one or more burr holes on both sides of the head to drain hematoma(s), you append modifier 50 (Bilateral procedure...) to 61154. "Chronic and subacute subdural hematomas can occur bilaterally as delayed manifestation of previous head injury in the older population. This may necessitate bilateral evacuation," says Przybylski.

Example: You may read that a patient who was diagnosed with epilepsy had a craniotomy 61533 (Craniotomy with elevation of bone flap; for subdural implantation of an electrode array, for long term seizure monitoring) to implant an electrode array for monitoring of seizure activity. Several weeks later, the patient developed symptoms of a subdural hematoma. The patient then underwent a burr hole drainage of the subacute subdural hematoma.

Here, you report 61154 for the drainage of the hematoma. Code 61154 applies to burr hole drainage of subdural and extradural hematoma(s), regardless of the cause of the hematoma. You append modifier 78 to indicate that it was a complication due to the original surgery. "Modifier 78 can be used if the patient must be taken to the OR a second time for an additional bleed in the same area," says Hall.

Don't forget: In addition, you would also report diagnosis code 997.02 (Iatrogenic cerebrovascular infarction or hemorrhage) to specify that the subdural hematoma occurred as a consequence of another procedure.

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