Neurosurgery Coding Alert

Question: In a patient with a brain tumor, our surgeon excised the growth and also evacuated a subdural hematoma through the same craniotomy approach. How can we report for these two procedures?

Kansas Subscriber

Answer: Your surgeon is performing two different procedures: excision of the tumorous growth and evacuation of the subdural hematoma. Submit code 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma) for the two procedures.

From the description, the evacuation for the subdural hematoma is an “incidental” procedure in the same location. The services of subdural hematoma evacuation, in this case, are inclusive to 61510.

Remember: Do notreport 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural) in addition to 61510 for evacuation of hematoma at the same site.

Same access directs to one code: Your surgeon has accessed the hematoma via the same craniectomy used for the tumor excision, so you should report only the tumor excision with code 61510. If there is significant additional physician work in managing the hematoma, you may consider appending modifier 22 (Increased procedural services) to 61510.

Watch the bundle: The Correct Coding Initiative (CCI) bundles 61312 into 61510. Code 61312 is a column 2 code for 61510, but a modifier is allowed in order to differentiate between the services provided. When applicable for a separate site craniotomy for a hematoma evacuation, use modifier 59 (Distinct procedural service) with code 61312.