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”?
The evacuation of the subdural hematoma was done via an open approach. In ICD-10-PCS, an “open” approach is defined as cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure. Additionally, it is not appropriate to report the root operation “Control” for evacuation of hematoma because it was caused by trauma in this case. Assign the following ICD-10-PCS code for the open evacuation of the subdural hematoma:
00C40ZZ Extirpation of matter from subdural space, open approach
A hematoma is a localized collection of blood outside of the vessel. A subdural hematoma can either be acute (subacute) or chronic. An acute subdural hematoma is characterized by a solid or gelatinous clot. A chronic subdural hematoma is typically composed of liquid matter rather than solid. If the procedural report only describes evacuation of liquid or fluid, use the root operation “Drainage.” The root operation “Extirpation” is used when solid matter is removed. If there is both drainage of liquid and cleaning out of solid matter, code only “Extirpation.” When this information is not available, “Extirpation” is the default.