Neurosurgery Coding Alert

Question: I'm coding for hemicraniectomy and duraplasty with diagnoses of post-trauma status and malignant brain swelling. Our neurosurgeon secured the patient's head in a Mayfield headholder, used a Midas Rex footplate to turn the craniotomy flap, and performed duraplasty with DuraGen. He also inserted an epidural drain. How should I report everything?

New Jersey Subscriber

Answer: Despite all your surgeon did, you'll probably report a single code for this procedure: 61322 (Craniectomy or craniotomy, decompressive, with or without duraplasty, for treatment of intracranial hypertension, without evacuation of associated intraparenchymal hematoma; without lobectomy), which includes the duraplasty. The drain and securing the patient's skull in a Mayfield headholder are considered bundled services.