Neurosurgery Coding Alert

Question: The surgeon performed elevation of a depressed skull fracture. How should I report this surgery?

Iowa Subscriber

Answer: It depends on a few factors that you haven’t listed in your question. Go back and check the notes and then choose among the following:

• Report 62000 (Elevation of depressed skull fracture; simple, extradural) when notes indicate that the surgeon “makes a burr hole in the scalp and elevates the depressed skull fracture … It is a closed fracture that has not reached the dura, the outer membrane covering the brain,” per Codify by AAPC.
• Report 62005 (… compound or comminuted, extradural) when notes indicate that the surgeon “incises the scalp and elevates a depressed skull fracture … This service is for a compound or comminuted fracture that may involve a break in, or loss of, skin and the skull bone being broken into fragments, but the break does not reached the dura, the outer membrane covering the brain,” reports Codify.
• Report 62010 (… with repair of dura and/or debridement of brain) when notes indicate that the surgeon “incises the scalp and elevates a depressed skull fracture … The provider also repairs the dura, the outer membrane covering the brain, and debrides the brain when necessary,” according to Codify.