Neurosurgery Coding Alert

Question: The neurosurgeon took a CT scan to confirm that the patient has a subdural hematoma. With the patient in park bench position, the neurosurgeon made a trephine margin, a linear paramedian incision, and he retracted the muscle and fascia. The neurosurgeon performed a craniotomy with a skull trephine craniotome to access the hematoma. Using direct visualization, the neurosurgeon used suction devices to suck the hematoma out. After removing the hematoma, the neurosurgeon irrigated the area and closed the surgical wound of the skull by central and peripheral dural hitch sutures. Which CPT^® code should I report for this procedure?

North Dakota Subscriber

Answer: Assuming the craniotomy was performed supratentorially (as most subdurals occur above the tentorium that separates the upper skull containing the four lobes from the lower skull containing the brainstem and cerebellum), you should report 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) for this procedure.

To choose the appropriate procedure, you must always look for specifics regarding the hematoma type in the operative note. According this op report, the hematoma was subdural. When you look at the code descriptor for 61312, you see that it applies to supratentorial, extradural, or subdural hematomas.

Also, in the op report, you can see that the neurosurgeon performed a craniotomy, which involves removing a bone plate and replacing it. Code 61312 is appropriate for either a craniectomy or a craniotomy, according to the code’s description.