Complications and surgical approach can drive your options.Coding for decompression and hematoma removal doesn't have to cause headaches. Learn to study your surgeon's approach and assign the best diagnosis to support medical necessity, and you'll steer clear of bundling issues for pain-free coding every time.
Look for More Complications
You can basically divide decompression procedures into two categories: those with the surgeon completing only decompression and those when he completes decompression and evacuates a hematoma.
CPT includes separate codes for each, such as 61105 (Twist drill hole for subdural or ventricular puncture) for decompression alone or 61108 (Twist drill hole[s] for subdural, intracerebral, or ventricular puncture; for evacuation and/or drainage of subdural hematoma) for decompression with evacuation of a hematoma. If you're coding decompression alone, choose the appropriate code from Column 1 in the chart on page 12.
If you're coding for decompression with evacuation of hematoma, choose from [...]