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 same physician following initial procedure for a related procedure during the postoperative period) to 61154. If the burr hole is on the opposite side (rather than a recurrence at the same site), append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period).
