Neurosurgery Coding Alert

Hint: Understand when to report 62010 versus 61313.

During a craniotomy, the surgeon removes a piece of the patient’s skull to access the inside of the brain for surgery. Craniotomies can be very tricky to code because of all the different components involved, but you don’t have to let this procedure trip you up.

Take a look at the following case study from Christina Ferraro, CMC, Carolina Orthopaedic & Neurosurgical Associates in Spartanburg, South Carolina, to help keep your craniotomy claims in tip-top shape.

Take a Look at Gunshot Wound Scenario

The case: A patient presented to the hospital with a gunshot wound through his right jaw, penetrating his right orbit and exiting through the right frontal bone. The patient underwent a head CT, which showed a comminuted fracture of the frontal bone with fractures of the frontal sinus and ethmoid bones. The patient previously underwent repair of the right mandible by head and neck service.

Surgeon 1 and the patient discussed a combined approach with plastic surgery, including Surgeon 2 for repair of the right orbital roof, frontal sinus, and right frontal bone.

Surgeon 1 took the patient to the operating room and placed him in a supine position on the operating table. The patient previously had a tracheostomy in place, which the anesthesia team used for oxygenation. Surgeon 1 placed an arterial line and put the patient in three-point fixation pins. Surgeon 1 shaved the patient’s scalp with clippers and prepped and draped the frontal regions from the right to the left temporal bone anterior to the right and left ears. Surgeon 1 marked out a bicoronal incision and injected 1 percent lidocaine with epinephrine along the incision site.

After a timeout was called, Surgeon 1 used a 10-blade scalpel to make the incision and placed Raney clips on the cut scalp edges. Surgeon 1 maintained the superficial temporal arteries on both sides and the periosteum for use later in the case. Once the incision was completed, Surgeon 1 reflected the scalp anteriorly and exposed both orbital rims. The comminuted fracture of the frontal bone was immediately evident, so Surgeon 1 removed the periosteum from the frontal bone bilaterally using sharp dissection. Surgeon 1 left this attached to a small pedicle near the right lateral orbital roof. Surgeon 1 then removed the bone fragments from the scalp and separated them from the dura. The bones were approximately shattered into five pieces, and Surgeon 1 was able to remove them without any damage to the superior sagittal sinus.

Next, Surgeon 1 carefully dissected off the dura and dissected down to the frontal sinus. Surgeon 1 sucked out the mucus from the frontal sinus and exposed the ethmoid sinus. Surgeon 1 noticed a fracture of the ethmoid bone, and a portion of this was removed. The entire right orbital roof was removed as this was fractured. The dura was breached via the exit wound, and Surgeon 1 opened the dura at the cut margins from posterior to anterior and reflected it medially and laterally. Once the brain was exposed, Surgeon 1 saw a large amount of clot in the right frontal lobe and removed this with suction. Surgeon 1 also removed the macerated right frontal pole and exposed the dura along the orbital roof. Surgeon 1 placed DuraSeal^® over the dissected brain surface. Surgeon 1 exposed the dural edge just posterior to the orbital rim and used a portion of the pericranium. Surgeon 1 stitched both interrupted and running interlocking 4-0 Nurolon^® sutures to attach the dura to the pericranium.

Then, Surgeon 2 examined the frontal sinus and designed a titanium plate to buttress the pericranium. Once the mucous membrane was removed from the frontal sinus, Surgeon 1 placed Betadine soaked Gelfoam into the frontal sinus and covered and sealed it with DuraSeal. Surgeon 1 irrigated copiously with vancomycin irrigation and then continued to stitch the pericranium to close the open dural spaces. Surgeon 1 injected irrigation into the frontal lobe region and did not see any leaks, so he reapproximated the right frontal bone with the orbital rim with the help of Surgeon 2. Titanium bur hole covers and dog bone plates were used to reapproximate the bone fragments. The surgeons also used a portion of mesh to cover the exit site over the right frontal bone. Once the cranioplasty was complete, the surgeons used two 4-0 Nurolon^® tack ups for central tack ups.

At this point, Surgeon 2 reapproximated the exit wound over the right frontal scalp and reapproximated the scalp flap at the site of the original incision. Surgeon 2 removed the patient from the three-point Mayfield fixation and wrapped his head after a subgaleal drain was put in place.

Discover Tricky Craniotomy Coding Solution

“This is a challenging case to code, given there are two major conditions being treated: an open comminuted fracture and an intracerebral frontal hematoma, both a consequence of a gunshot wound,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

ICD-10 codes: The fractures sustained include right orbital roof, frontal sinus, and ethmoid bones. You should report the following ICD-10 codes on this claim, according to Przybylski:

• When choosing a primary diagnostic code, you should report the right orbital roof fracture with S02.121B (Fracture of orbital roof, right side, initial encounter for open fracture).
• You should report the ethmoid fracture with S02.2XXB (Fracture of nasal bones, initial encounter for open fracture).
• You should report the frontal fractures with S02.0XXB (Fracture of vault of skull, initial encounter for open fracture).

Don’t miss: “The intraparenchymal frontal hematoma would be described based on whether there is some loss of consciousness,” Przybylski says. “Assuming no loss of consciousness, S06.340A (Traumatic hemorrhage of right cerebrum without loss of consciousness, initial encounter) describes the initial encounter of a traumatic hemorrhage of the right cerebrum without loss of consciousness. If there is some duration of loss of consciousness, there are other options in this family to note the duration of lost consciousness.”

The choice of diagnostic codes should be prioritized based on the most to least relevant for the treatment being rendered, Przybylski adds.

CPT^® codes: Similarly, the procedure code(s) should be chosen based on the most inclusive code Przybylski says. While there are fracture repair codes for treatment of brain and dural injury (62010 craniotomy for elevation of depressed skull fracture with dural repair and debridement of brain), the most definitive procedure performed here is a craniotomy for evacuation of supratentorial intracerebral hemorrhage, which you should report with 61313 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral).

“While 62010 would include fracture repair, 61313 would be the more definitive procedure and would include dural repair and bone flap repair and replacement,” Przybylski says. “There is a surgical principle that you close/ repair what you open. The plating of fracture fragments and dural repair would be considered incidental to the craniotomy and evacuation of frontal hematoma and would therefore not be separately reportable.”

Modifier alert: Since two surgeons worked together as primary surgeons for different portions of this procedure, each may report 61313 with modifier 62 (Two surgeons).

Both surgeons should dictate separate operative notes summarizing the work each performed as a primary surgeon, Przybylski adds. There would not be separate reporting of cranioplasty or treatment of the orbital fracture/ frontal sinus evacuation once you have reported 61313.