Reader questions:
Remember modifier for burr hole follow-up
Published on Mon Nov 23, 2009
Question: A patient presents with a subdural hemorrhage and requires a craniotomy. A few days later the patient has a recurrent subdural hemorrhage that requires evacuation via a burr hole. How should I code these procedures, and what are the correct diagnoses? Utha Subscriber Answer: Code the craniotomy with 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) and diagnosis 432.1 (Subdural hemorrhage), then the burr hole with 61154 (Burr hole[s] with evacuation and/or drainage of hematoma, extradural or subdural). If the recurrent subdural did not result from a complication of the original surgery (as opposed to the disease process), report diagnosis 432.1 again. Modify it: Because your surgeon performed the second procedure within the craniotomy's global period, you'll need to include a modifier explaining the situation. If the burr hole was in the same location, append modifier 78 (Unplanned return to the operating/procedure room by the [...]
