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Craniotomy to Evacuate a Hematoma in CPT

craniotomy to evacuate a hematoma in CPT
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** This post was reviewed and updated on December 23, 2023. **

Name That Code

Question:  A patient suffers an extradural hematoma in the supratentorial area of the brain, and the neurosurgeon performs a craniotomy to evacuate it. What CPT code should be assigned for this procedure?

Answer:

61312

Selecting the most specific code for a craniotomy to evacuate a hematoma in CPT comes down to the documentation, the type of hematoma, where it is located, and the approach to treat it. 

Coding for Craniotomy to Evacuate a Hematoma

The documentation states the hematoma type is extradural, located in the supratentorial area of the brain, and the approach is a craniotomy to evacuate it.

Locate and Verify

First, we want to look up Craniotomy/Evacuation of hematoma  61312-61315. In the Tabular, our correct code can be verified as:

61312, 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 code descriptions either involve the evacuation of a different type of hematoma than documented or refer to a different brain area. Whether the documentation states the surgeon performed a craniotomy or craniectomy, CPT code 61312 covers either procedure.

Additional Information

Now that we have discussed how to locate and verify the correct code for the above coding scenario let’s dive into additional facts that will give you a better understanding of the topic: anatomy of the brain, effects of an extradural and subdural hematoma, diagnosis and treatment of a hematoma, and how a craniotomy procedure is performed to evacuate an extradural hematoma in the supratentorial area.

Anatomy of the Brain

cerebrum, cerebelum, and tentorium

According to the National Center for Biotechnology Information, the supratentorial area is the upper part of the brain that contains the cerebrum, lateral and third ventricles, cerebral spinal fluid, choroid plexus, hypothalamus, pineal gland, pituitary gland, and optic nerve. The infratentorial area is the lower back part of the brain. It contains the cerebellum, tectum, fourth ventricle, and brain stem. The tentorium separates the supratentorial and the infratentorial areas. The skull and meninges protect the brain and spinal cord.

What is an Extradural Hematoma?

According to the Mayo Clinic, an extradural hematoma, also known 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 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. 

epidural hematoma vs. subdural hematoma

What is a Subdural Hematoma?

A subdural hematoma occurs when arteries or veins, usually veins, rupture between the brain and the 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 lose consciousness and possibly die gradually

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 of Epidural or Subdural Hematoma

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.

Craniotomy Procedure to Evacuate Extradural Hematoma

A craniotomy procedure may vary based on the patient’s condition and the 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 sutured tightly closed to prevent any cerebrospinal fluid leakage. Sometimes, a drain is put in place temporarily to prevent a reaccumulation of blood. The bone flap is then returned to its original location over the dura and closed with steel sutures. 

craniotomy to evacuate a hematoma in cpt
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