Neurosurgery Coding Alert

Question: Our surgeon placed a vagal nerve stimulator for a patient who later developed a hematoma. Our surgeon then did another procedure to evacuate the neck hematoma. During this process, our surgeon removed the generator and then put back the generator after the procedure. Do we need to report code 61885 with 10140 or is 10140 alone sufficient for these services?

Codify  Subscriber

Answer: You should use only CPT® code 10140 (Incision and drainage of hematoma, seroma or fluid collection).  Taking out the generator and then putting it back after the neck hematoma is drained would be considered a part to the evacuation of the hematoma. Hence, you need not submit code 61885 (Insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array) in addition to code 10140. There is no problem with the nerve stimulator. It was removed to make way for evacuation of hematoma and post procedure the same stimulator was re inserted at its original place (same site).  If the service is performed during the global period for the insertion, you should append modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to reflect the return to the operating room to treat a complication related to the initial procedure.