Neurosurgery Coding Alert
Check Approach for Pneumocephalus Evacuation
Question: A patient who underwent an evacuation of a subdural hematoma in the past presents to our neurosurgeon. Our neurosurgeon performs a right frontal burr hole with evacuation of pneumocephalus. This pneumocephalus was compressing the cerebral hemispheres. How can we report this procedure?
New York Subscriber
Answer: For the evacuation of the pneumocephalus, you report code 61250 (Burr hole[s] or trephine, supratentorial, exploratory, not followed by other surgery). From the description of the procedure provided, this seems the sole maneuver performed to cause the air to escape. You may check if your surgeon adopted an approach from below the tentorium. If so, you submit code 61253 (Burr hole[s] or trephine, infratentorial, unilateral or bilateral).
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