Neurosurgery Coding Alert

Question: I understand that you should include control of bleeding during a surgical procedure as a component of the primary surgical procedure, but what if you must return the patient to the operating room for control of bleeding the following day?

New Hampshire Subscriber

Answer: If the surgeon returns the patient to the operating room for control of bleeding as a primary procedure, you may report the procedure separately. In neurosurgical practice, in fact, such "control of bleeding" is anything but a minor procedure.

For instance, if the surgeon must return a patient to the operating room for evacuation of a subdural hematoma -- 432.1 (Subdural hemorrhage) -- following intracranial surgery, you would report 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural).

Note that if the return to the operating room occurred within the global of another surgical procedure, you will want to 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 the appropriate procedure code.

As you note, when a neurosurgeon performs a major procedure, control of bleeding is an included component of the surgery. If your physician documented that he spent significant time and effort controlling bleeding during a major procedure, however, you may try to gain additional reimbursement by appending modifier 22 (Increased procedural services) to the appropriate CPT surgical code.

Example: During treatment of a ruptured proximal carotid intracranial aneurysm by occluding the cervical and intracranial carotid artery, the neurosurgeon must work extensively to prevent excessive blood loss. You should report 61705 (Surgery of aneurysm, vascular malformation or carotid-cavernous fistula; by intracranial and cervical occlusion of carotid artery) and append modifier 22.

Tip: Provide an op report and cover letter explicitly describing the unusual nature of the surgery and requesting additional compensation.