Neurosurgery Coding Alert

Look for dura repair and debridement in addition to repair of depressed fracture.

If you tend to lose your calm when coding depressed skull fracture repairs, worry no longer. All you need to remember is to go beyond fracture repair and look for additional repair and debridement.

Benefit: You'll be well on the way to selecting the right code for surgical elevation of depressed skull fractures if you can do the following:

1. Confirm type of fracture,
2. Look for any debridement that your physician performed, and
3. Code specifically for dural repair.

Help's here: We've got all the info you need to suss out the specifics of depressed skull fracture surgery. Read on to learn what codes to apply for simple, compound, and comminuted fractures in addition to their respective follow-up repairs and debridements.

Know Depressed Fracture Surgery Basics

For surgical management of a depressed skull fracture, your surgeon will make an incision in the scalp, gain access to the skull fracture, maneuver the broken bones to reassemble them, and fix the bones using sutures, screws, and plates. To keep the original shape of the skull, your surgeon may use metallic mesh or bone cement.

Why surgical repair?  According to the UCLA Neurosurgery website, your surgeon might attempt surgical repair of depressed skull fracture in patients with:

1. Open fractures of the skull,
2. Leakage of cerebrospinal fluid from the depressed fracture,
3. Depression of the skull greater than 8 mm to 10 mm,
4. Depression of skull greater than the thickness of the skull, and
5. Signs of brain dysfunction consequent to the depressed fracture.

Source: Check UCLA's specifications yourself at: http://neurosurgery.ucla.edu/skull-fracture.

"There are a number of variables that a neurosurgeon considers when deciding whether to surgically treat a depressed skull fracture, including anatomical location, associated brain injury, cosmetic consequences, and duration of an overlying open scalp laceration," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison, New Jersey.

Choose 62000 for Simple Skull Fractures

When your surgeon repairs a simple skull fracture, you report code 62000 (Elevation of depressed skull fracture; simple, extradural).

Example:  You may read that a 60-year-old patient reported in the hospital with a history of falls. Your surgeon documented redness, swelling, and bruises on the left frontal area. There was no evidence of laceration. During the period of observation, the patient developed localized motor weakness in the limbs on the right side. Your surgeon ordered a computed tomography, which confirmed a "depressed fragment of frontal bone associated with hypodensities in the adjacent brain parenchyma." In this case, hypodensities are suggestive of edema in the brain parenchyma, and you infer no evidence for dural lacerations that would require repair.

What "simple" means: The code descriptor for 62000 clearly specifies that the code is for "simple" depressed fractures. The term "simple" here implies a closed fracture. Hence, you report 62000 when you confirm in the operative note that there was no laceration or wound in the scalp region overlying the skull fracture, and that the provider performed no dural repair.

Elevation of skull fracture is inclusive in 62000: In this example, your surgeon may decide to elevate the fracture, as there is a documented brain dysfunction with the fracture. In the operative note, you will confirm elevation of the skull fracture when you read that your surgeon elevated any piece(s) of bone that were pressed inward and repositioned them to bring them back to their correct position(s). If necessary, your surgeon may use a metal wire or plates to maintain the elevated piece(s) of the skull fracture. Your surgeon may then close the skin with stitches or staples.

Turn to 62005 for Compound, Comminuted Fractures

When you read that your surgeon stabilized and repositioned a compound or comminuted depressed skull fracture, you should submit code 62005 (Elevation of depressed skull fracture; compound or comminuted, extradural).

Example: You may read in the operative note that your surgeon performed an elevation of compound, comminuted, depressed skull fracture and also did methylmethacrylate cement cranioplasty to repair the gap left from bone fragments too small to replace. In this case, you can confidently report code 62005.

Compound vs. comminuted: Typically, compound skull fractures are associated with open scalp wounds. Comminuted skull fractures imply that the fracture resulted in multiple fragments of the skull. Comminuted fractures may or may not be associated with open scalp wounds. The term compound refers to the open wound with communication of the fracture site to the skin surface.

Look for Repair, Debridement on Fracture Repairs

Whenever your surgeon repairs a simple, compound, or comminuted depressed fracture of the skull, you should also confirm whether your surgeon did any repair of the dura. Additionally, you need to check if your surgeon also debrided any of the devitalized brain tissue. You submit code 62010 (Elevation of depressed skull fracture; with repair of dura and/or debridement of brain) for repair and/or debridement. This code is inclusive of any dural repair and/or debridement when done with elevation of depressed skull fracture.

Tip:  Do not forget to check for any debridement or dural repair in the operative note. Make sure you do not miss the repair or debridement in a simple, compound, or comminuted fracture.

Repair May Be Incidental to Craniectomy

When your surgeon performs a craniectomy or craniotomy to evacuate a hematoma, you do not separately report the fracture repair that your surgeon performed in the same session. This is because the treatment of the depressed fracture is an incidental part of the closure of the more extensive procedure of craniotomy for evacuation of the subdural or intraparenchymal hematoma.

Explanation: Since the surgeon would perform a craniotomy with bone flap closure for evacuation of an intracranial hematoma regardless of the presence of a skull fracture, the fracture repair overlying the hematoma site is considered incidental and not separately reportable.

Tip: Do not report fracture repair services along with codes 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) through 61315 (Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar) when fracture repair is a component of the evacuation of an epidural, subdural, or parenchymal hematoma.