Neurosurgery Coding Alert

Question: While recovering from a craniotomy, the patient suffers a “brain hematoma,” according to the notes. What is a brain hematoma, and how do I choose an ICD-10-CM code for one that occurred post-procedure?

Indiana Subscriber

Answer: A hematoma occurs when blood pools outside a blood vessel. This could occur in an organ, soft tissue, or just in body space.

Since the hematoma occurred in the brain and after a procedure on the nervous system, you’d report G97.61(Postprocedural hematoma of a nervous system organ or structure following a nervous system procedure) to represent the patient’s condition. If the intracranial hematoma occurred after the surgeon performed a procedure on any other part of the body (i.e., not the nervous system), you would report G97.62 (Postprocedural hematoma of a nervous system organ or structure following other procedure).

Don’t forget seroma: The G97.6- (Postprocedural hematoma and seroma of a nervous system organ or structure following a procedure) code set also features codes for postoperative seroma; this condition features a pocket of clear fluid that can pool beneath the skin after surgery. If this complication arises after a surgery, you would report either G97.63 (Postprocedural seroma of a nervous system organ or structure following a nervous system procedure) or G97.64 (Postprocedural seroma of a nervous system organ or structure following other procedure), depending on encounter specifics.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC