Neurosurgery Coding Alert

Hint: Keep an eye on bundles with other surgical procedures.

When reporting a decompression procedure, you’ll set yourself up for claims success if you accurately identify what was done to correct the hematoma and the approach your surgeon used.

Range of clinical options: “Methods for decompressions can vary including relieving intracranial pressure with ventriculostomy for CSF drainage, craniectomy to create more room for swelling, and evacuation of compressive lesions like a hematoma,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Step 1: Confirm if Hematoma was Evacuated

You can basically divide decompression procedures into two categories: (1) those when your surgeon does a decompression alone and (2) those when your surgeon completes the decompression and evacuates a hematoma.

The first step is to check if your surgeon also evacuated a hematoma. “Remember that a hematoma evacuation does not necessarily require craniotomy or craniectomy. For example, subacute or chronic subdural hematomas may be evacuated through burr hole or twist drill holes,” says Przybylski.

Checki8ng for evacuation of a hematoma will help you to make way to the correct code. Example: you report code 61105 (Twist drill hole for subdural or ventricular puncture) for CSF decompression alone and 61108 (Twist drill hole[s] for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma) for decompression by evacuation of a hematoma.

Another possible code for decompression is 61120 (Burr hole[s] for ventricular puncture [including injection of gas, contrast media, dye, or radioactive material]) which you report when your surgeon does a ventricular puncture by making a burr hole rather than twist drill hole.

When your surgeon does a decompressive craniectomy or craniotomy, you have the following possible choices:

• 61322 -- Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy
• 61323 -- Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; with lobectomy
  
• 61330 -- Decompression of orbit only, transcranial approach
  
• 61340 -- Subtemporal cranial decompression (pseudotumor cerebri, slit ventricle syndrome)
  
• 61343 -- Craniectomy, suboccipital with cervical laminectomy for decompression of medulla and spinal cord, with or without dural graft (e.g., Arnold-Chiari malformation)
  
• 61345 -- Other cranial decompression, posterior fossa
  

When your surgeon makes a burr hole to evacuate a hematoma in addition to the decompression, you look at the following codes:

• 61154 -- Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural
  
• 61156 -- Burr hole(s); with aspiration of hematoma or cyst, intracerebral
  

Similarly, when your surgeon performs a craniotomy or craniectomy to do a decompression and hematoma evacuation, you have the following possible choices:

• 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.
  

Tip: Look for specifics on the hematoma type in the operative note. “It is important to determine whether the hematoma is intraparenchymal (in the brain) or extraparenchymal (subdural or epidural) to identify the appropriate code,” says Przybylski.

Step 2: Ascertain the Approach

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 or 61156
• Craniotomy or craniectomy -- Codes 61312, 61313, 61314, or 61315.

Differences: You will find the detailed description of the approach used in the operative note. Burr holes and twist drills are procedures to make an opening in the skull. One basic difference between burr hole and twist drills is that burr hole is an operating room procedure and twist drill is an emergency room or bedside procedure (though it can still be performed in the OR). Burr holes are power equipment and twist drills are hand operated.

Craniectomy and craniotomy are procedures that involve removal of part or whole section of skull bone. You can look for the term ‘bone flap removal’ in the operative note. Craniectomy involves removing bone piecemeal without replacement, but craniotomy involves removing a bone plate and replacing it. To select the most appropriate code, check if your surgeon also ‘closed’ the defect in the skull.

Pin Down the Right Diagnosis Codes

When reporting a hematoma due to traumatic brain injury, you report ICD-9 code 854.00 (Intracranial injury of other and unspecified nature without mention of open intracranial wound with state of consciousness unspecified) (ICD-10 code S06.890A, Other specified intracranial injury without loss of consciousness, initial encounter). “There are a long list of diagnosis codes that include the location of hemorrhage, whether an injury with fracture is open or not, and the duration of loss of consciousness, if any. These descriptors are important in order to choose the correct diagnosis code,” says Przybylksi.

You can also look at more specific hematoma options like the following:

• 431 -- Intracerebral hemorrhage (I61.X options in ICD-10)
• 432.x -- Other and unspecified intracranial hemorrhage (I62.X options in ICD-10)
• 851.xx -- Cerebral laceration and contusion (S06.33XX options in ICD-10)
• 852.xx -- Subarachnoid, subdural, and extradural hemorrhage, following injury (S06.6X0A options in ICD-10)
• 853.xx -- Other and unspecified intracranial hemorrhage following injury (S06.3X0A options in ICD-10).

Key: You can look for terms like ‘intracerebral, subarachnoid, subdural, or extradural’ in the clinical record or in the report of imaging studies, say a CT scan.

“Keep in mind that decompression (other than CSF drainage) is not typically performed with subarachnoid hemorrhage,” says Przybylski. “However, a decompressive craniectomy without hematoma evacuation may be indicated when the only hemorrhage is in the subarachnoid space and sever brain swelling occurs (e.g. Diffuse axonal injury).”

Check if Any Bundles Apply

The Correct Coding Initiative (CCI) edits bundle the codes for hematoma evacuation into many brain surgery procedures. You should never miss upon checking the possible edits before separately submitting hematoma evacuation codes.

When your surgeon does a procedure to treat an aneurysm, the procedure is inclusive of any evacuation of clots or control of bleeding. Thus, you may not be able to earn for the two procedures separately. This means that you cannot code separately for bleed control when reporting aneurysm codes 61697 (Surgery of complex intracranial aneurysm, intracranial approach; carotid circulation) - 61702 (Surgery of simple intracranial aneurysm, intracranial approach; vertebrobasilar circulation).

Example: Code 61313 is a column 2 code for 61702. This implies that you need a modifier to differentiate between the services provided. When reporting 61313 with 61702, you append modifier 59 (Distinct procedural service) to 61313.

• You 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).

Remember: If your surgeon evacuates a hematoma in the region of an open surgical approach for aneurysm or vascular malformation, the procedures are considered bundled. For an open surgical approach for surgery of aneurysm or malformation, you choose the appropriate code from 61680 (Surgery of intracranial arteriovenous malformation; supratentorial, simple) - 61711 (Anastomosis, arterial, extracranial-intracranial [e.g., middle cerebral/cortical] arteries). You would not typically report these codes with 61312 or 61313.

However, evacuation of hematoma is not included with the procedure of coiling of aneurysm. When your surgeon attempts coiling of an aneurysm through the percutaneous route, you confirm the central or non-central approach and accordingly report code 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., a vascular malformation], percutaneous, any method; non-central nervous system, head or neck [extracranial, brachiocephalic branch]). These codes have no bundle with the hematoma evacuation codes, for example, 61312 or 61313. “This is because the coiling treatments are percutaneous endovascular procedures and there is no overlapping intraoperative work with craniotomy for hematoma evacuation,” says Przybylski.