Neurosurgery Coding Alert

If you can confirm the infratentorial location of the hematoma, you will turn to codes 61314 & 61315.

When your neurosurgeon performs an intracranial hematoma evacuation, you must always read the documentation to identify the hematoma’s location and the exact type.

Discover handy tips on how to correctly code intracranial hematoma evacuations in your office.

Tip 1: Rely on These Codes for Evacuation or Drainage of Intracranial Hematomas

A hematoma is defined as an unusual collection of blood outside of the blood vessels due to an internal hemorrhage. A subdural or extradural hematoma is often associated with head injuries. The neurosurgeon can remove these life-threatening conditions through suction or direct removal. To perform this service, the surgeon typically has to perform either a craniotomy or a craniectomy.

You can turn to the following codes for the evacuation or drainage of intracranial hematomas:

• 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural)
• 61313 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; intracerebral)
• 61314 (Craniectomy or craniotomy for evacuation of hematoma, infratentorial; extradural or subdural)
• 61315 (Craniectomy or craniotomy for evacuation of hematoma, infratentorial; intracerebellar)

Tip 2: Pinpoint Hematoma’s Exact Location

If your surgeon performs the evacuation of a hematoma in the patient’s skull, you must first check the medical documentation to confirm the hematoma’s site. Review the operative note for details on whether the hematoma was supratentorial or infratentorial. “Most hematomas will be found in the supratentorial location. Look for documentation describing posterior fossa, suboccipital or cerebellum to identify an infratentorial location,” says Gregory Przybylski, MD, immediate past chairman of neuroscience and director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

Supratentorial hematoma: If you read that the hematoma was supratentorial, you can narrow down your choice of codes to 61312 and 61313

Infratentorial hematoma: If you can confirm the infratentorial location of the hematoma, you turn to codes 61314 and 61315.

Don’t miss: The tentorium is a dividing membrane that is formed by extension of the dura. It separates the cerebellum, located in the posterior fossa, from the occipital lobes of the cerebrum. It is also called the tentorium cerebelli or cerebellar tentorium.

Tip 3: Specify the Hematoma Type

Once you can confirm the location of the hematoma as being above or below the tentorium, you must know if the hematoma that the surgeon drained was extradural, subdural, or parenchymal. So, you’re looking at how deep the hematoma was.

If the hematoma is subdural or extradural, you will choose between codes 61312 and 61314.

If the hematoma is deeper in the brain tissue, you’ll report codes 61313 and 61315 for the intracerebral and intracerebellar hematomas, respectively.

“The key difference is whether the hematoma is located in brain tissue itself (intraparenchymal) or on either side of the dural membrane that lies between the skull and the brain,” Przybylski says.

Coding example: The surgeon made two burr holes — one positioned on the thickest portion of the chronic subdural hematoma and another a little anterior to the coronal suture. The surgeon then opened the dura and the outer membrane with small incisions. Next, the surgeon evacuated the subdural hematoma. After the spontaneous outflow stopped, the surgeon coagulated the edges of the dura and membrane to achieve hemostasis. Finally, the surgeon irrigated the subdural cavity with copious amounts of isotonic saline.

Solution: In this case, you can confirm that your surgeon is draining a supratentorial subdural hematoma, so you should report code 61312.

Tip 4: See if Hematoma Evacuation is Sole Procedure Performed

Your surgeon may perform a hematoma evacuation along with other procedures such as a tumor excision or vascular abnormality. In these cases, you must know when you can report the two procedures together.

Your first step is to find the tumor and hematoma locations. If your surgeon evacuates the hematoma at the same site where a tumor excision is done, you cannot separately report the hematoma with the tumor excision. “The hematoma evacuation would be considered incidental to the primary goal of tumor excision,” Przybylski says.

Coding example: The surgeon performed a tumor excision and at the same site also performed an evacuation of an intraparenchymal hematoma. You should report 61510 (Craniectomy, trephination, bone flap craniotomy; for excision of brain tumor, supratentorial, except meningioma). You cannot bill 61510 and 61313 together.