Neurosurgery Coding Alert

Use add-on code when surgeon removes skull portion.

When your surgeon performs a craniotomy or craniectomy, you’ll have to know why they performed the procedure, as code choice depends on it. When making that code choice, a knowledge of key terms is necessary so you don’t slip up and choose the wrong code.

Why? Brain anatomy is complicated, and some of the terms are quite similar. The difference between two codes can sometimes be the result of a few different letters in a descriptor term.

But once you know the codes, and the terms, craniotomy and craniectomy coding can be much less confusing. Read on for more information on coding these surgical services.

Know These Codes

The craniotomy and craniectomy codes we’ll be addressing in this article are as follows:

• 61304 (Craniectomy or craniotomy, exploratory; supratentorial)
• 61305 (…infratentorial (posterior fossa))
• 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural)
• 61313 (… intracerebral)
• 61314 (Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural)
• 61315 (… intracerebellar)
• +61316 (Incision and subcutaneous placement of cranial bone graft (List separately in addition to code for primary procedure))

Note: The advice given in the article is for the 61304-+61316 code set.

Know the Key Terms

The 61304-+61316 code descriptors are full of terms that look sort of similar … but aren’t. Check out this glossary of key terms you’ll need to know before trying to selects the proper craniotomy/craniectomy code:

• Supratentorial: The region of the brain above the tentorium cerebelli.
• Infratentorial: The region of the brain below the tentorium cerebelli.
• Extradural: Occurring outside the dura matter but within the skull.
• Subdural: Occurring between the dura matter and the arachnoid membrane.
• Intracerebral: Occurring within the cerebrum.
• Intracerebellar: Occurring within the cerebellum.
• Hematoma: A collection of blood outside of blood vessels.

Best bet: Learn these terms if you don’t know them already. It will help immensely when you are scouring notes for surgical details. For instance, notes might indicate that a procedure occurred above the tentorium cerebelli; with the info above, you’ll know that this is a supratentorial surgery.

Know the Different Procedure Types

There are two main types of craniotomy and craniectomy in the 61304-+61316 code set. The 61304 and 61305 codes are for exploratory craniotomy/craniectomy. These types of surgeries are often performed on patients with “an open head injury that may require removal of foreign bodies or bone fragments,” explains Tammy Allen, manager of coding operations at Health Fidelity in Trenton, Michigan. “Think blow to the head due to some accident or trauma.”

Your surgeon will not perform 61304 and 61305 services often. Fewer than 500 annual cases of 61304 were reported to the Centers for Medicare & Medicaid Services (CMS) over the last decade. Given the high quality of neuroimaging available by computed tomography (CT) or magnetic resonance imaging (MRI) scanning, it has become unusual to perform a craniotomy without generally knowing the diagnosis and choosing a more specific procedure code.

The 61312-61315 code set is used for craniotomy or craniectomy performed to treat a subdural hematoma, Allen explains. Typically, patients with severe head trauma need these surgeries, and that trauma could be due to any type of severe head trauma causing event: car accident, fall striking head, etc.

In contrast, 61312-61315 are much more commonly reported.

Example: A patient is brough to the emergency department (ED) with impaired consciousness after a high-speed motor vehicle accident. Examination showed the patient to be unconscious with a Glasgow Coma Score of 7. Computed tomography (CT) imaging showed a large left subdural hematoma that was not associated with a skull fracture. The individual was taken emergently to the operating room (OR) for a left frontoparietal craniotomy for evacuation of the traumatic subdural hematoma, and a ventriculostomy was placed on the contralateral right side through a burr hole.

For this claim, you’d report 61312 and 61210 with modifier 59 (Distinct procedural service) appended. You’d append S06.5X9A (Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter) to 61312 and 61210 to represent the patient’s injury.

Know the Add-on Code