Selecting the most specific code for a craniotomy to evacuate a hematoma in CPT comes down to the documentation, where the hematoma is located, and the approach taken to treat it.
This post was updated on October 21, 2022.
Name That Code!
A patient suffers an extradural hematoma in the supratentorial region of the brain, and the neurosurgeon performs a craniotomy to evacuate it.
What CPT code should be assigned for this procedure?
61312 refers to Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural
CPT codes for craniectomy or craniotomy for evacuation of hematomas are found by looking at codes 61312-61315.
But how do we find the correct code in the CPT coding manual Index?
Craniotomy to Evacuate a Hematoma
Locate and Verify
First, we want to look up Craniotomy, evacuation, hematoma 61312-61315.
In the Tabular, 61312 can be verified as:
Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural.
The other choices in that code range, which are incorrect for this scenario, are:
- 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.
All three of these code descriptions either involve evacuation of a different type of hematoma than documented or a different region of the brain.
Whether the documentation states the surgeon performed a craniotomy or craniectomy, CPT code 61312 covers either procedure. In addition, it doesn’t matter if the documentation indicates the type of hematoma was extradural or sudural. Code 61312 applies to either type.
A craniotomy procedure may vary based on the patient’s condition and physician’s practices. However, when a craniotomy is performed to evacuate an extradural hematoma, the scalp is incised, and then the scalp and bone flaps are lifted to expose the extradural hematoma. Biopsy forceps, gentle suction, and irrigation are used to remove the collection of blood.
Once the procedure is complete, the exposed brain is covered with the dural flap and is sutured tightly closed so as to prevent any cerebrospinal fluid leakage. Sometimes a drain is put in place temporarily instead to drain any fluid. The bone flap is then returned to its original location over the dura and closed with steel sutures.
According to the Mayo Clinic, an extradural hematoma, also referred to as an epidural hematoma, occurs when an artery or vein ruptures between the outer surface of the dura mater and the skull. Usually it is an artery that ruptures. This rupture causes blood to then leak between the dura mater and skull, and a mass forms and presses on the brain tissue. Trauma is the most common cause of this type of hematoma.
An extradural hematoma can cause drowsiness or even coma immediately following trauma. Death can also occur without immediate treatment if an artery in the brain is affected.
A subdural hematoma occurs when arteries or veins, usually veins, rupture between the brain and outermost of three membrane layers that cover the dura mater. The leaking blood forms a hematoma that presses on the brain tissue. A hematoma that gets larger can cause a person to gradually lose consiousness and possibly die.
Subdural hematomas are broken down into acute, subacute, and chronic types. Because permanent brain damage can occur, medical attention is needed for all three of these types. People at greater risk of subdural hematoma are the elderly, those who take aspirin or other daily blood thinning medication, and those who abuse alcohol.
Diagnosis and Treatment
Diagnosing an epidural or a subdural hematoma may include such imaging techniques as a computerized tomography (CT) scan, magnetic resonance imaging (MRI) scan, or an angiogram.
Treatment may require surgical drainage or a craniotomy.
Supratentorial Region of the Brain
The supratentorial region is the upper part of the brain that contains the cerebrum, lateral and third ventricles, choroid plexus, hypothalamus, pineal gland, pituitary gland, and optic nerve, according to the National Center for Biotechnology Information. The supratentorial region of the brain lies above the tentorium cerebelli, a fold of dura mater that divides the frontal and occipital lobes of the cerebrum from the cerebellum.