AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2015 Issue 3; Ask the Editor

Open Evacuation of Subdural Hematoma

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”? ...

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