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Neurosurgery Coding Alert

Reader Questions:

Hematoma Evacuation Requires Extra Work

Published on Wed Sep 08, 2010

Question: Can you help me report the following procedure?

Procedure: 1. Occipital and suboccipital craniectomy (right occipital craniectomy more than left side; bilateral suboccipital craniectomy)

2. Evacuation of epidural hematoma

Description of Procedure: After standard preparation of the patient, an incision was made starting above the level of the inion working inferiorly to the level of C1 . Soft tissue layers, including muscle and ligamentum nuchae were incised in sequential fashion. Bone flap turned with Midas Rex involving the bilateral suboccipital regions and bilateral occipital regions, right side more than the left. A large epidural hematoma was readily encountered and removed with gentle irrigation and suction. Fibrin glue placed along the epidural surface. Large dry Gelfoam placed on epidural surface. Irrigation of soft tissue layers. Closure of fascia, muscle, and galea with vicryls, staples for skin. The patient was returned to neutral position.

Florida Subscriber

Answer: You would report 61314 (Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural). If the surgeon documents significantly more than the typical amount of bone resection for hematoma evacuation, you may consider appending modifier 22 (Increased procedural services).

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