Neurosurgery Coding Alert

Question: To fix a depressed skull fracture, my neurosurgeon made an incision in the scalp, gained access to the skull fracture, maneuvered the broken bones to reassemble them, and fixed the bones using sutures, screws, and plates. This was a simple skull fracture, according to the medical documentation. There was no laceration in the scalp region, and my neurosurgeon didn’t perform a dural repair. My neurosurgeon did use a metal write to maintain the elevated piece(s) of the skull fracture. Which CPT^® code should I report on my claim?

North Carolina Subscriber

Answer: You should report 62000 (Elevation of depressed skull fracture; simple, extradural) in this case.

Don’t miss: The code descriptor for 62000 specifies that the code is for simple depressed fractures. The term “simple” implies a closed fracture. So, you should report 62000 when you confirm in the operative note that there was no laceration or wound in the scalp region overlying the skull fracture, and that the neurosurgeon did not perform dural repair.

On the other hand, if your neurosurgeon had stabilized and repositioned a compound or comminuted depressed skull fracture, you would report 62005 (Elevation of depressed skull fracture; compound or comminuted, extradural). The term compound refers to the open wound with communication of the fracture site to the skin surface. Comminuted skull fractures imply that the fracture resulted in multiple fragments of the skull.

Remember: In the operative note for a depressed skull fracture, you must confirm elevation of the skull fracture when you read that your surgeon elevated any piece(s) of bone that had been pressed inwards and repositioned them to their correct position. If necessary, your neurosurgeon may use a metal wire or plates to maintain the elevated piece(s) of the skull fracture. Your neurosurgeon may then close the skin with stitches or staples.