Neurosurgery Coding Alert

Question: A 60-year-old patient reported in the hospital with a history of falls. The neurosurgeon 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. The neurosurgeon ordered a computed tomography, which confirmed a “depressed fragment of frontal bone associated with hypodensities in the adjacent brain parenchyma.” Hypodensities are suggestive of edema in the brain parenchyma, and I infer no evidence for dural lacerations that would require repair. What CPT^® code should I report?

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Answer: When the neurosurgeon repairs a simple skull fracture, you should report code 62000 (Elevation of depressed skull fracture; simple, extradural). The code descriptor for 62000 clearly specifies that the code is for “simple” depressed fractures. The term “simple” here implies a closed fracture. So, you should 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.

Don’t miss: The elevation of the skull fracture is inclusive in 62000. In this case, the neurosurgeon 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 the neurosurgeon elevated any piece(s) of bone that were pressed inward and repositioned them to bring them back to their correct position(s). If necessary, the neurosurgeon may use a metal wire or plates to maintain the elevated piece(s) of the skull fracture. The neurosurgeon may then close the skin with stitches or staples.