Neurosurgery Coding Alert

Site, location are your best guides.

When your neurosurgeon performs hematoma evacuations as a sole procedure and as part of other surgeries like tumor excisions, you'll need to be confident about looking for bundled evacuations and when to append modifier(s) to ethically boost your reimbursement. Let these three questions and answers guide you to the right codes.

Below are the four codes you have for the evacuation or drainage of intracranial hematomas:

• 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural)
• 61313 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral)
• 61314 (Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural)
• 61315 (Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar)

1. Where's the Hematoma Located?

When you read that your surgeon did an evacuation of hematoma in the skull, you'll need to confirm the hematoma site. Review the operative note for details on whether the hematoma was supratentorial or infratentorial. "Most hematomas will be found in the supratentorial location. Look for documentation describing posterior fossa, suboccipital or cerebellum to identify an infratentorial location," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

If you read that the hematoma was supratentorial, you can narrow down your choice of codes to 61312 and 61313. If, however, you confirm the infratentorial location of the hematoma, you turn to codes 61314 and 61315.

Anatomy refresher: The tentorium is a dividing membrane that is formed by extension of the dura. It separates the cerebellum, located in the posterior fossa, from the occipital lobes of the cerebrum. It is also called the tentorium cerebelli or cerebellar tentorium.

2. What's the Hematoma Type?

Once you confirm the location of the hematoma as being above or below the tentorium, you turn to confirming the type of hematoma further. You need to ascertain if the hematoma that your surgeon drained was extradural, subdural, or parenchymal. In other words, you're looking at how deep the hematoma was.

For the subdural or extradural hematomas, you'll choose between 61312 and 61314. Similarly, if the hematoma is deeper in the brain tissue, you'll report codes 61315 and 61316 for the intracerebral and intracerebellar hematomas, respectively. "The key difference is whether the hematoma is located in brain tissue itself (intraparenchymal) or on either side of the dural membrane that lies between the skull and the brain," says Przybylski.

Example: The op note below illustrates hematoma location and type:

"Two burr holes were made, one positioned on the thickest portion of the chronic subdural hematoma and another a little anterior to the coronal suture. With a craniotomy, the dura and the outer membrane are opened with a small incision. The subdural hematoma was evacuated. After the spontaneous outflow stopped, the edges of the dura and membrane were coagulated to achieve hemostasis. The subdural cavity was irrigated with copious amounts of isotonic saline....."

In this case, you confirm that your surgeon is draining a supratentorial subdural hematoma and report code 61312.

3. Is the Hematoma Evacuation the Sole Procedure?

Your surgeon may be doing a hematoma evacuation along with other procedures like a tumor excision or vascular abnormality. In such cases, you need to know when you can report the two procedures together so you're capturing all your deserved pay.

First, find the tumor and hematoma locations. If your surgeon evacuates the hematoma at the same site where a tumor excision is done, you cannot separately report the hematoma with the tumor excision. "The hematoma evacuation would be considered incidental to the primary goal of tumor excision," says Przybylski.

Example: If you read your surgeon did a tumor excision and at the same site also did an evacuation of an intraparenchymal hematoma, you report code 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). You cannot bill 61510 and 61313 together.

Tip: Removal or drainage of a hematoma at the same area of the tumor excision is a component of the tumor excision and not separately billable.

This pair, 61510 and 61312 or 61313, can be unbundled in appropriate circumstances. If your surgeon performs the two procedures at different sites, you can append modifier 59 (Distinct procedural service) and report the two codes together. So, if you read that your surgeon performed a contralateral subdural hematoma evacuation on the left and a supratentorial tumor excision on the right, you report 61510 and 61312-59. "This circumstance might be seen when a seizure or trauma results in a hemorrhage from striking the head, causing the hematoma not directly related to the tumor location itself," says Przybylski.

Additionally, you may turn to modifiers RT (Right side) and LT (Left side) to further demonstrate that your surgeon performed the hematoma removal and tumor excision at separate locations. For example, you report the tumor excision on the right side followed by hematoma removal at a different site on the left side as 61512-RT and 61312-59-LT. You will however need to keep complete documentation in support of your claim.