Neurosurgery Coding Alert

Question: A patient with recurrent subdural hygroma (CSF fluid collection) and a subdural hematoma reports to the neurosurgeon, who removes the bone flap to evacuate the hematoma and hygroma. She then places tenting sutures on the flap and connects it to the dura to alleviate any brain pressure. Finally, the surgeon drills a burr hole, places a subdural peritoneal shunt and replaces the bone flap. How should I report this encounter?

Vermont Subscriber

Answer: You should be able to report a pair of codes for this instance; one for the evacuation and one for the shunt placement. But you-ll need a little help from modifier 51 (Multiple procedures) to show the payer that the shunt creation was a separate procedure.

On the claim, you should:

- report 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) for the hematoma/hygroma evacuation.

- report 62192 (Creation of shunt; subarachnoid/subdural-peritoneal, -pleural, other terminus) for the shunt placement.

- link 432.1 (Subdural hemorrhage) to 61312 and 62192 to represent the patient's hematoma and hygroma. (Note: ICD-9 uses the same code for subdural hygroma and subdural hematoma).

- append modifier 51 to 62192 to show the insurer that the procedures were separate.