Coding, Classification & Reimbursement

1.  Subdural Hematoma via Burr Holes - Percutaneous vs Open

Posted 05-11-2017 12:59
Good Afternoon -

I am working on a DRG Denial for a case where the patient had a subdural hematoma and was taken to the OR for drainage via burr holes.  I have included an excerpt from the Operative Report below.  We assigned 009400Z (Drainage of subdural space with drainage device, open approach) for the procedure.  The reviewer feels that the code should have been 009430Z (Drainage of subdural space with drainage device, percutaneous approach).

I have done some research and found the following doing a Google search, as well as a series of Coding Clinics from 3rd Quarter 2015.
CDI Talk: http://www.cditalk.com/threads/icd10-indexing-of-burr-hole-procedure.772/
HIA Connect: http://hiaconnect.com/2015/12/11/icd-10-tidbit-for-the-week-12112015/
AAPC: https://www.aapc.com/memberarea/forums/131818-burr-hole-pcs.html

I wanted to get thoughts/feedback from others if you have had this scenario.  My initial thoughts are to agree with the reviewer and that the approach should have been percutaneous.

Thanks for reviewing!!!
Rachel


Excerpt from Operative Report:
Surgery: Under illumination of a portable headlight and 2.5x surgical telescopes, a 10 blade was used to incise the skin and galea aponeurotica of the surgical site on the right. Monopolar cautery was used to control superficial bleeding and clear the galea aponeurotica from the skull. A self retaining retractor was used to hold back the skin and galea. A Midas Rex drill with a perforator bit was used to make a burr hole. This was then repeated on the left. Bone wax was used to fill the corticocancellous rim and control bleeding. The dura under each burr hole was coagulated with bipolar forcepts and the 11 blade was used to make a cruciate incision in the dura on each size. Chronic subdural fluid was immediately expressed from each burr hole. Copious irrigation was then used in each burr hole until the runoff was clear. A burr hole cover was placed on each side and secured with 5mm self drilling screws.

Closure: A 4 flat jp drain was laid over each the left and right burr hole and the distal tubing run inferiorly to exit the skin posterior to the incision. The galea was closed with interrupted 2.0 Vicryl sutures and 3.0 nylon in the skin. The subdural drains were secured with a 3.0 nylon suture.

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Rachel Stiles, RHIT
UR Coding Appeals Specialist
NC
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2.  RE: Subdural Hematoma via Burr Holes - Percutaneous vs Open

Posted 05-11-2017 22:25
I believe it is an open approach because a flap had to be used to close the site.    If it were percutaneous would the site need a flap to close ?   

Sent from my iPhone





3.  RE: Subdural Hematoma via Burr Holes - Percutaneous vs Open

Posted 05-12-2017 02:50
Edited by Sree Lekshmi L 05-12-2017 03:01
Hello Rachel,

The excerpt you provided from the operative report and the coding clinic guidance for burr holes substantiate that the scenario you mentioned should be coded as a per cutaneous approach. (ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 2015 Pages: 11-12 Effective with discharges: October 7, 2015 states "A burr hole is a small hole that is drilled through the skull to assess a targeted local area. In this case, the correct approach is "percutaneous." The ICD-10- PCS defines "percutaneous" as entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure. Assign the following ICD-10-PCS code: 009430Z  Drainage of subdural space with drainage device, percutaneous approach")


We have another coding clinic:  ICD-10-CM/PCS Coding Clinic, Third Quarter ICD-10 2015 Pages: 10-11 Effective with discharges: October 7, 2015, which talks about an open evacuation of subdural hematoma. Two burr holes were made in this scenario , but it clearly states the incision was a "question mark type incision" and this incision was extended to connect the parietal and subtemporal burr holes. The guidance in this coding clinic was to consider "Open" as the approach value.

Due to copyright restrictions I cannot paste the coding clinics as such to this page. But, if you search with the search word "Burr Hole" in Coding Clinic Reference, you will be able to see many scenarios where burr holes and its coding is detailed.

Hope this help you to clear the air.

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Sree Lekshmi MBA, CDIP, CCS
Senior Manager Medical Coding
Pacific Global Inc.
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4.  RE: Subdural Hematoma via Burr Holes - Percutaneous vs Open

Posted 05-12-2017 08:05
Here's a nice article.

http://hiaconnect.com/2015/12/11/icd-10-tidbit-for-the-week-12112015/

 

Happy Friday!!

This week we are focusing on coding procedures when burr hole is made (open vs. percutaneous). We've had a few recommendations involving changing the approach from percutaneous to open when burr hole is made.

A single burr hole with instrumentation placed through the hole into the intracranial spaces would be coded as a percutaneous approach.  Not all procedures that include "burr hole" would be reported as percutaneous.  In some cases, the surgeon will make multiple burr holes and then remove the bone that is between the burr holes (like in a triangle) to actually get down to the operative site.  This would be coded as an open approach because the surgeon is cutting down to visualize the area.  In these cases, the surgeon will most likely describe the dura and the brain and document what he is seeing as he approaches the target area.  Coders should be cautious and read the entire operative note to determine if the procedure is taking place through the burr hole itself or did the surgeon make a larger area using the burr hole in order to complete the surgery via open approach.

Also, look for any repair/dura patch that may be necessary in order to complete the procedure, stabilization, and computer assistance used.

Coding References/examples of procedures including burr holes:

  • Coding Clinic, Third Quarter ICD-10-2015 Pages: 12-13
  • Coding Clinic, Third Quarter ICD-10-2015 Pages: 27-28
  • Coding Clinic, Third Quarter ICD-10-2015 Pages: 10-11
  • Coding Clinic, Third Quarter ICD-10-2015 Pages: 11-12
  • Coding Clinic, Third Quarter ICD-10-2015 Page: 12


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Dara Bermick, CCS
Inpatient Auditor and Consultant
dbermick@gmail.com
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5.  RE: Subdural Hematoma via Burr Holes - Percutaneous vs Open

Posted 05-12-2017 08:39
Coding Clinic 3rd qtr 2015 p.10-11 states that if two burr holes are then connected by a craniotomy incision it is coded to an open approach.

Coding Clinic 3rd qtr 2015 p.11-12 states that burr hole drainage of subdural hematoma codes to the approach percutaneous.
In this case I believe the approach is percutaneous.

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Sarah Hamblin, BA RHIT
Remote Coding Specialist
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