Neurosurgery Coding Alert

Coding for decompression and hematoma removal doesn't have to cause headaches. Learn to study your surgeon's approach and assign the best diagnosis to support medical necessity, and you'll steer clear of bundling issues for pain-free coding every time.

You can basically divide decompression procedures into two categories: those with the surgeon completing only decompression and those when he completes decompression and evacuates a hematoma.

CPT includes separate codes for each, such as 61105 (Twist drill hole for subdural or ventricular puncture) for decompression alone or 61108 (Twist drill hole[s] for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma) for decompression with evacuation of a hematoma. If you're coding decompression alone, choose the appropriate code from Column 1 in the chart on page 12.

If you're coding for decompression with evacuation of hematoma, choose from Column 2.

"All the hematoma codes are used fairly frequently, except for orbital," says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison. Przybylski adds that the surgeon typically will use the word "hematoma" in his documentation, so watch for those notations to help your coding cause.

Once you determine whether a hematoma was present, your next coding clue comes through the surgeon's approach. The three options are:

• Twist drill -- Codes 61105, 61107 (Twist drill hole[s] for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device), or 61108

• Burr hole -- Codes 61120 (Burr hole[s] forventricular puncture [including injection of gas, contrast media, dye, or radioactive material]), 61154 (Burr hole[s] with evacuation and/or drainage of hematoma, extradural or subdural), or 61156 (Burr hole[s]; with aspiration of hematoma or cyst, intracerebral)

• Craniotomy or craniectomy -- Codes 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural), 61313 (... intracerebral), 61314 (Craniectomy or craniotomy for evacuation of hematoma, infratentorail; extradural or subdural), or 61315 (... intracerebellar).

Differences: "Burr holes require power equipment and therefore are typically operating room procedures," Przybylski explains. "Twist drills are hand operated and are typical for bedside and emergency room procedures."

Details: Craniectomy involves removing bone piecemeal without replacement, but craniotomy involves removing a bone plate and replacing it. Knowing that detail helps narrow your code selection. "Look for bone flap removal," recommends Beth Carter, CPC, CCS, CCS-P, in the coding department of Carolina Neurosurgery and Spine Associates in Charlotte, N.C. Carter also says to check the "closing" documentation to determine whether the surgeon replaced a bone flap since that can affect your code selection.

Successful reimbursement requires careful diagnosis coding ��" and that means reporting the most specific diagnosis possible.

Trap: Don't simply code traumatic brain injury (854.00, Intracranial injury of other and unspecified nature; without mention of open intracranial wound) or aneurysm (437.3, Cerebral aneurysm, nonruptures).

Instead, code the specific hematoma your surgeon treats.

More specific options can include the appropriate codes from:

• 431 -- Intracerebral hemorrhage

• 432.x -- Other and unspecified intracranial hemorrhage

• 851.xx -- Cerebral laceration and contusion

• 852.xx -- Subarachnoid, subdural, and extraduralhemorrhage, following injury

• 853.xx -- Other and unspecified intracranial hemorrhage following injury.

Watch for documentation terms such as intracerebral, subarachnoid, subdural, or extradural, Carter says. "Also look for CT results if the doctor isn't clear," she advises.

Correct Coding Initiative (CCI) edits bundle the codes for hematoma evacuation into many brain surgery procedures, so check the latest edits before separately submitting hematoma codes.

Example: The control of bleeding and evacuation of clots is part of all procedures, including aneurysm surgery and ligation of blood vessels. Because of this, you can't code separately for bleed control when reporting aneurysm codes 61697-61702 or skull-based codes for vessel ligation (61601-61615).

Exception: If your surgeon evacuates a hematoma in the region of an open surgical approach for aneurysm or vascular malformation, the procedures are considered bundled. Evacuation of hematoma is not included with coiling of aneurysm, however.

CPT does not include a code specifically for coiling of aneurysm, but you report it according to the surgeon's approach. Submit 61624 (Transcatheter permanent occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method; central nervous system [intracranial, spinal cord]) or 61626 (Transcatheter permanent occlusion or embolization [e.g., for tumor destruction, to achieve hemostasis, to occlude a vascular malformation], percutaneous, any method; non-central nervous system, head or neck [extracranial, brachiocephalic branch]) for percutaneous approach. For an open surgical approach instead, choose the appropriate code from 61680-61711 (codes from "Surgery for Aneurysm, Arteriovenous Malformation, or Vascular Disease").

You can report other procedures in conjunction with evacuation of hematoma when appropriate, thanks to modifier 59 (Distinct procedural service). Use modifier 59 to unbundle evacuation of hematoma when:

• your surgeon performed the evacuation separately either before or after the other procedures, or

• your surgeon completed the evacuation in a separate anatomical location (usually by a separate incision).

As always, append modifier 59 to the code with the lowest relative value units (RVUs), Carter says.