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Question: Encounter notes indicate that the neurosurgeon used a manual twist drill to create a hole in the patient’s skull and drain a subdural hematoma. First, they made a scalp incision to peel away the skin from the affected area. Then, they placed the drill over the affected area of the skull and drilled until it got past the periosteum and exposed the dura. The surgeon then drained the abscess through the twist drill hole. How should I report this encounter?

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Answer: For this patient, you’ll report 61108 (Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma). This coding is pretty straightforward; because the patient had a subdural hematoma, 61108 is a pretty obvious code choice. However, there are times when selecting a code might not be so clear.

In addition to 61108, there are two other twist drill code choices. You’ll use the 61105 (Twist drill hole for subdural or ventricular puncture) code when the surgeon creates the hole to alleviate pressure in preparation for surgery.

If the surgeon makes the twist drill hole in order to install a drainage catheter or an intracerebral monitoring device, you’ll opt for 61107 (Twist drill hole(s) for subdural, intracerebral, or ventricular puncture; for implanting ventricular catheter, pressure recording device, or other intracerebral monitoring device). If, however, the hole is for “intracranial neuroendoscopic ventricular catheter placement,” CPT^® instructs you to opt for +62160 (Neuroendoscopy, intracranial, for placement or replacement of ventricular catheter and attachment to shunt system or external drainage (List separately in addition to code for primary procedure)) instead of 61107. Remember that +62160 is an add-on code and you will need a primary surgical code on the claim as well.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC