Neurosurgery Coding Alert

Question: In a patient who developed motor weakness following an accident, our surgeon performed a repair of simple skull fracture. How can we report this procedure? What does the term ‘simple’ imply in the operative note?

Alaska Subscriber

Answer: From the description provided, your surgeon repairs a simple skull fracture. You report code 62000 (Elevation of depressed skull fracture; simple, extradural) for this service. Since the motor weakness has already set in, your surgeon had to decide to elevate the fracture as this is clearly indicative of associated brain dysfunction.

Term “simple” implies closed fracture: The code descriptor for 62000 clearly specifies that the code is for simple depressed fractures. The term ‘simple’ here implies an intact scalp overlying the fracture. Hence, you report 62000 when you confirm in the operative note that there was no laceration or wound in the scalp region overlying the skull fracture.

Confirm elevation in the operative note In the operative note, you confirm elevation of the skull fracture when you read that your surgeon elevated any piece(s) of bone that had been pressed inwards and repositioned them to their correct position. If necessary, your surgeon may use a metal wire or plates to maintain the elevated piece(s) of the skull fracture. Your surgeon may then close the skin with stitches or staples.

Note this code for compound and comminuted skull fractures: When your surgeon stabilizes and repositions a compound or comminuted depressed skull fracture, you report code 62005 (Elevation of depressed skull fracture; compound or comminuted, extradural). Compound skull fractures describe fractures associated with an overlying open scalp wound. However, comminuted fractures may or may not be associated with an open scalp laceration.

Check for dural lacerations: Closed depressed skull fractures may or may not be associated with dural lacerations. You should review the operative note in detail to differentiate among simple and compound fracture repairs as well as for any dural repair and/or debridement of injured brain tissue.

Confirm any repair or debridement: For any depressed skull fracture, whether simple, compound, or comminuted, you should always confirm if your surgeon does any repair of the dura or debrides brain tissue. For those services, turn to code 62010 (Elevation of depressed skull fracture; with repair of dura and/or debridement of brain).