A 26-year old patient is admitted through the ER after being involved in an acci

Question

A 26-year old patient is admitted through the ER after being involved in an accident. Patient was brought in via ambulance with a severe head injury and denies any LOC Initial work-up in the ER reveals an intracranial injury and the patient is taken imme- diately to the OR where the surgeon performs an evacuation of an epidural hema- toma. The physician incises the scalp and peels it away from the area to be drilled After drilling a burr hole in the cranium and identifying the hematoma via CT scar the hematoma is decompressed and bleeding is controlled. The hematoma is located outside the dura just under the periosteum. The scalp is repositioned and sutured into place. The patient tolerates the procedure well and is sent to recovery. What is the correct code set for physician reporting of this procedure? ICD-10-CM and CPT Code(s): a. S06.4X0A, 61154 b. S06.369A, 61108 C. S06.4???, 61156 d. S06.369A, 61156

Explanation / Answer

ICD-10-CM and CPT COde(S): C.S06.4X0A, 61156

a. S06.4X0A - Epidural Haemorrhage without loss of consciousness.

61154 - Twist drill burr holes or Trephine procedures on the skull, Meninges, and the brain.

CPT code is not appropriate. This is the wrong option.

b. S06.369A - Traumatic hemorrhage of the cerebrum unspecified, with loss of consciousness of unspecified duration, initial encounter.

61108 -  Twist drill hole(s) for subdural, intracerebral, or ventricular puncture.

ICD-10-CM and CPT is not an appropriate code. This is also the wrong answer.

c. S06.4X0A -  Epidural Haemorrhage without loss of consciousness.

61156- Burr hole

  This is the correct code for this procedure.

d. S06.369A - Traumatic hemorrhage of the cerebrum unspecified, with loss of consciousness of unspecified duration, initial encounter.

61156 - Burr hole

ICD-10 -CM code is not correct in this code.

Therefore the option C. S06.4X0A, 61156 is the correct answer.

Related Questions

Navigate

• Browse (All)
• Browse A
• Subjects

---

---

Integrity-first tutoring: explanations and feedback only — we do not complete graded work. Learn more.