Neurosurgery Coding Alert

Question: The neurosurgeon performed a left temporal craniotomy for evacuation of a subdural hematoma, replaced the bone flap and closed the incision. While in recovery, the patient got worse, and the surgeon performed a CT that showed a subdural hematoma (SDH) in the frontoparietal area and in the postoperative temporal space. About five hours after the first craniotomy, the surgeon performed a left frontoparietal craniotomy for evacuation of SDH, removed the old bone flap and extended the craniotomy to the parietal and frontal regions. Can I report more than one code in this scenario?


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Answer: You should be able to report a pair of CPT codes in this instance.

First, report 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) for the initial craniotomy. Then report 61312 again with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended to show that the second procedure was related but more extensive than the first.

Generally, you-ll have to use modifier 58 in the following situations:

- when a second procedure is prospectively planned at the time of the initial procedure;

- when the second procedure is more extensive than the original procedure; or

- when the surgeon conducts a therapeutic procedure following a diagnostic surgical procedure.

In this instance, the neurosurgeon extended the craniotomy and evacuated the hematoma from a larger area, so the second of these criteria applies. On the claim, be sure that the documentation includes separate op reports for both craniotomies.

Remember: Modifier 58 resets the postoperative clock, beginning a new post-op period, and does not result in reduced payment for the service. However, be prepared to appeal the claim if payers attempt to substitute modifier 78 (Return to the operating room for a related procedure during the postoperative period) instead.