Hoping someone can help me with this. I have a general surgery doc who only performed CPT +61316 which is an add on code. According to both him and the neurosurgeon that is the ONLY part of the surgery that he helped with. The neurosurgeon billed 61312 as the primary procedure. This is a procedure he performs fairly frequently. He is not even present for the craniectomy.

Thanks for your help!

Kelly – CPC

Preoperative Diagnosis
1. Traumatic subdural hematoma
2. Intractable elevated intracranial pressures

Postoperative Diagnosis
1. Traumatic subdural hematoma
2. Intractable elevated intracranial pressures

Operation
Subcutaneous abdominal preservation of autologous bone flap

Technique
Indications:
Male Thirty is an unknown aged male who has sustained a traumatic SDH and intractable elevated ICPs despite medical management. Patient is undergoing a decompression hemicraniectomy due to syndrome. Placement of subcutaneous abdominal bone flap was requested.

Procedure:
Patient was already in OR suite and intubated. Abdomen was prepped and draped in standard fashion. Three minutes of drying time were allowed for drying of the abdominal Chloraprep. A midline incision was made below the umbilicus. Dissection was carried down to the fascia. Next, a subcutaneous pocket was made above the fascia on the left side. Space to fit the bone flap was made. Hemostasis was achieved. Next, the autologous bone flap was placed into the subcutaneous pocket. The pocket was closed using a running 2-0 Vicryl suture. The skin was closed using staples. Sponge and needle counts were correct at the end of the case. Sterile dressing was applied.

Patient was transported back to ICU in stable condition.

Surgical Sweep Complete (Yes/No/Not Applicable)
Not applicable