Neurosurgery Coding Alert

You can bank upon the side of fracture and initial encounters to find the right code.

Fractures in the skull base are complex to treat yet simple to report. You can adopt an easy stepwise approach to find the correct diagnosis code for skull base fractures. Make sure you have checked for the following before you can finalise the diagnosis code for skull base fractures:

1. Check if the fracture is on the right or the left side of the skull base.
2. Confirm if the fracture is a closed or open fracture.
3. Document first or subsequent encounter for the fracture.
4. Find out the reason for subsequent encounter for skull base fracture.
5. Watch out for sequelae to the fracture.

Confirm Initial Encounter for Skull Base Fractures

For initial encounters for fracture of the skull base on the right side, you submit code S02.101A (Fracture of base of skull, right side, initial encounter for closed fracture) or S02.101B (Fracture of base of skull, right side, initial encounter for open fracture. You can get the right code by checking for a closed vs. open fracture of skull base.

Similarly, for fractures on the left slide, you have codes S02.102A (Fracture of base of skull, left side, initial encounter for closed fracture) and S02.102B (Fracture of base of skull, left side, initial encounter for open fracture).

For subsequent encounters, you have the following codes:

• S02.101D, Fracture of base of skull, right side, subsequent encounter for fracture with routine healing
• S02.101G, Fracture of base of skull, right side, subsequent encounter for fracture with delayed healing
• S02.101K, Fracture of base of skull, right side, subsequent encounter for fracture with non-union
• S02.102D, Fracture of base of skull, left side, subsequent encounter for fracture with routine healing
• S02.102G, Fracture of base of skull, left side, subsequent encounter for fracture with delayed healing
• S02.102K, Fracture of base of skull, left side, subsequent encounter for fracture with non-union

Tip: For subsequent encounters in skull base fractures, you need to check if the encounter was for routine or delayed healing or a non-union of the fracture. “Reporting of the delayed and non-union diagnostic codes is most likely going to be associated with complications of the skull based fracture such as delayed cerebrospinal fluid leak,” says Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.

Do Not Ignore Unspecified Side

When your surgeon does not specify the side for the initial encounter for skull base fracture, you submit code S02.109A (Fracture of base of skull, unspecified side, initial encounter for closed fracture) for closed fractures and code S02.109B (Fracture of base of skull, unspecified side, initial encounter for open fracture) for open fractures.

For subsequent encounters, you can choose from codes S02.109D (Fracture of base of skull, unspecified side, subsequent encounter for fracture with routine healing), S02.109G (Fracture of base of skull, unspecified side, subsequent encounter for fracture with delayed healing) and S02.109K (Fracture of base of skull, unspecified side, subsequent encounter for fracture with non-union) for routine and delayed healing and non-union.

Look For Sequelae to Skull Base Fracture

If your physician documents that the patient developed deficits or neurological damage subsequent to the skull base fracture, you submit code S02.101S (Fracture of base of skull, right side, sequela) for the right sided fractures and code S02.102S (Fracture of base of skull, left side, sequela) for the left sided fractures. When your surgeon does not specify the side, you submit code S02.109S (Fracture of base of skull, unspecified side, sequela). “Possible sequelae that may prompt reporting of these diagnostic codes include CSF leak, infection and cranial nerve palsies,” Przybylski says.

Make note: Table 2 lists skull base fracture codes that have been deleted. Remember to strike them off your coding database.