Case
-T12-2C OPERATIVE REPORT, SUBDURAL HEMATOMA This is not the same patient as in T12-2B.
LOCATION: Inpatient, Hospital
PATIENT: Robert Vobr
ATTENDING PHYSICIAN: Ronald Green, MD
SURGEON: Timothy Pleasant, MD
PREOPERATIVE DIAGNOSIS: Subdural hematoma, traumatic
POSTOPERATIVE DIAGNOSIS: Subdural hygroma, traumatic
ANESTHESIA: Local; standby
PROCEDURE: The patient's head was prepped and draped in the usual manner. An incision was made in the frontal left and left posterior parietal area. The skin was incised. Retractor was placed. Bone was isolated. Perforator was utilized. Burr hole was made, and the dura was incised and coagulated. Clear CSF (cerebrospinal fluid) exuded. This was a subdural hygroma. The brain was deep to the subdural hygroma. We placed two Penrose drains and then closed the wounds with 2-0 Vicryl on the galea with surgical staples on the skin. Dressing was applied. The patient was discharged to recovery.
T12-2C:
SERVICE CODE(S): ___________________________________________________
ICD-10-CM DX CODE(S): ______________________________________________

Question

Quizplus · Accepted Answer

The Answer is Professional Services: 61154 (Burr Hole, Skull, Drainage, Hematoma)
ICD-10-CM DX: S06.5X9A (Injury, intracranial, subdural hemorrhage, traumatic)
Explanation: The service is the removal of a subdural hygroma, which is a subdural hematoma that has broken through the arachnoid membrane. The service is reported with 61154, which is a burr hole(s) with evacuation and/or drainage or a hematoma (either extradural or subdural).
The diagnosis is subdural hygroma. In the Index of the ICD-10-CM under "Hematoma, brain, subdural" you are directed to see "Injury, intracranial, subdural hemorrhage." The coder then needs to determine if the hematoma was with an open intracranial wound or if it was nontraumatic.
Since the report indicates the hematoma as traumatic, report code S06.5X9A. The 7th character "A" reports the initial encounter.
The student may inquire about the parenthetical word "traumatic" after the subterm of hematoma, brain in the Index. According to the coding conventions, that parenthetical word is a supplemental word (a nonessential modifier) and may be present or absent in the diagnostic statement.

Case -T12-2C OPERATIVE REPORT, SUBDURAL HEMATOMA This Is Not the Same