Neurosurgery Coding Alert

Question: A patient who had a craniotomy 8 years ago presented with an infection of the wound. Can we use codes 10180, 110xx. The operative report reads as under:

"....hair was shaved exposing the open wound and copious irrigation was started. We opened the incision a little more & visualized the plates beneath the skin. This was cleaned with curette and suction. We irrigated the epidural space copiously with antibiotic solution and 1/2 strength peroxide. We removed the margins of the skin and the bone that was infected. We left a drain & closed......."

Georgia Subscriber

Answer: It is not very clear from the operative note what the exact procedure was. If your surgeon only did irrigation and scalp debridement, you may report 10180 (Incision and drainage, complex, postoperative wound infection). Alternatively, you may consider 61501 (Craniectomy; for osteomyelitis) if the bone was infected and debrided.