Wiki Burr Hole or Craniotomy?

[jshaw8808]

I have a case of a subdural hematoma that was evacuated via a procedure in which, "A burr hole was made and a long craniotomy was fashioned using the drill. The bone was removed..."

I understand that the approach is crucial in coding these types of procedures, and my initial inclination was to report 61154 (Burr hole(s) with evacuation and/or drainage of hematoma, extradural or subdural) rather than 61312 (Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural). However, since the burr drill was used to create a long craniotomy, does that push this procedure over into the territory of 61312?

Thanks

James Shaw, CPC-A

 

[cpc2007]

I would code 61312 in this case. Sometimes a surgeon will make one or more burr holes to create a bone flap and be able to make the craniotomy to gain access (sounds like what happened in this case to me).

Kim
www.codingmastery.com