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Neurosurgery Coding Alert

Coding Case:

Heed These Pointers For Tallying Subdural Taps In Infants

Published on Thu Aug 02, 2012

Hint: Laterality does not matter but be sure to track the number of attempts. When your neurosurgeon performs a subdural tap in an infant as a diagnostic, stabilizing, or life-saving procedure, don't focus on the intent of the tap but instead keep a count of the number of subsequent taps your surgeon performs to recoup all your earned reimbursement. "Subdural drainage in infants may require a series of percutaneous drainage taps to manage reaccumulation of the subdural fluid," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.Use the op note that follows to guide your subdural tap coding: Operative note: "The child was placed in a supine position and secured in an immobilizer. All appropriate monitoring, ancillary personnel, and resuscitation equipment were confirmed. Small area of hair was clipped or shaved around the target site of the tap. The site of the tap was [...]
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