AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2015 Quarter 3; Ask the Editor
Open Evacuation of Subdural Hematoma
The patient is a construction worker, who fell 10 feet from scaffolding, striking his head. He was diagnosed with right subdural hematoma, and emergency craniotomy with evacuation of subdural hematoma was done. During surgery, a question mark incision was made, subtemporal burr hole was created, and evacuation was done. A parietal burr hole was then placed and organized subdural hematoma was further evacuated. The craniotomy incision was extended to connect the burr holes, and additional blood covering the entire exposed brain was irrigated. Is the burr hole coded as an open or percutaneous approach, and should the root operation be “Control” or “Extirpation”? ...
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Article Overview
This premium article focuses on ICD-10-PCS coding considerations for a surgical evacuation of a subdural hematoma following traumatic head injury. It is aimed at coding professionals who need help interpreting operative documentation for approach selection and root operation assignment in neurosurgical procedures. The discussion centers on the procedure context, body site access, and how the operative details affect code selection.
Why This Topic Matters
Accurate procedure coding for intracranial hematoma evacuation depends on correctly identifying the operative approach and the procedure category reflected in the documentation. This article helps readers understand how to interpret a neurosurgical operative report for ICD-10-PCS reporting.
What You Will Learn
- How an intracranial evacuation procedure is described in operative documentation
- How ICD-10-PCS approach terminology is applied in a cranial surgery context
- How the procedure context influences selection of the appropriate root operation category
- How to evaluate documentation for traumatic subdural hematoma surgery for coding purposes
Who Should Read This
- Inpatient coders
- Coding educators
- Neurosurgery coding specialists
- Clinical documentation integrity professionals
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