Neurosurgery Coding Alert

Question: The surgeon removed a subdural hematoma via craniectomy. Rather than reattach the bone flap, he closed with a silastic dural expansion graft. Which code is appropriate for a graft of this type? Nevada Subscriber Answer: Most payers, whether Medicare or third-party, will not reimburse separately for a silastic dural expansion graft. Instead, they consider the graft as included in the major procedure. Specifically, payers reason that the surgeon must close the dura whether or not he uses the graft. The fact that a silastic graft is synthetic -- rather than a harvested autograft -- is another factor. Because there is little work involved in acquiring or securing the graft, payers reason that no additional reimbursement is warranted. In this case, you would report the craniotomy with subdural hematoma evacuation using 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural), with no separate code for the graft. If the surgeon places the graft at a different date (but still within the initial surgery's global period), you may be able to gain separate reimbursement for the secondary replacement of the bone flap using 62143 (Replacement of bone flap or prosthetic plate of skull) appended with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period). In addition, you may gain separate reimbursement if the surgeon performs cranioplasty, using an autograft rather than a synthetic graft, to repair the skull at a later date. If so, be sure to note the autograft size from the operative report and, depending on that data, report either 62146 (Cranioplasty with autograft [includes obtaining bone grafts]; up to 5 cm diameter) or 62147 (... larger than 5 cm diameter) appended with modifier 58.