Evacuation of Subdural Hematomas (SDH)

This installment of “In the kNOW” will address procedures for evacuation of subdural hematomas.  A subdural hematoma (SDH) is a collection of blood on the brain.  Causes of SDHs include trauma, iatrogenic, or spontaneous with most cases of SDH being trauma related.  Subdural hematomas may be characterized as chronic, subacute, or acute.  Regardless of the type of SDH, it may be necessary to evacuate the hematoma to alleviate pressure on the brain.  These procedures will often be accomplished with the use of burr holes and/or craniotomy.  These techniques may have coders questioning the appropriate approach (open vs. percutaneous) or root operation (extirpation vs. drainage vs. control).  So let’s look at a few examples for clarification.

After a fall from a 12 ft. ladder, a patient developed a right subdural hematoma.  The patient was brought to the OR, given general anesthesia, and then after a timeout, his right hemicranium was shaved and prepped, and antibiotics were administered.  Frontal and parietal burr holes were marked as well as marking for a craniotomy if necessary.  Then both frontal and parietal incisions were made and the areas retracted.  Pilot holes were initiated with bone wax applied.  There was coagulation at the dura.  Cruciate incision was made.  A large amount of blood flowed through both burr holes.  More blood was evacuated through an opening in the posterior membrane.  Placement of a drain was not necessary as I could see the brain elevate to the surface of the skull.  Likewise, there was no need for a craniotomy, since decompression was achieved.  Closure was then begun with Gelfoam in the burr holes, cranial plates secured over the burr holes, and the wounds closed in layers.  A sterile dressing was applied after Neosporin swabbed.  The patient was in satisfactory, stable condition upon discharge to PACU.

In the above procedure, the root operation will be Drainage which by definition is the taking or letting out of fluids and/or gases from a body part.  Drainage applies here because blood was evacuated rather than a clot.  Also, the 3rd Qtr. 2015 Coding Clinic has stated that Control would not be the appropriate root operation since this was a traumatic event that caused the bleed.  Using the index, we see that Drainage, subdural space, intracranial leads to table 0094.  Next we must determine the approach for the procedure.  In this case, only burr holes were made.  No craniotomy was performed, so the approach will be percutaneous.  Our final ICD-10-PCS code will be 00943ZZ since there was no drainage device.

If we change the scenario above and say the SDH was an organized hematoma (clot) that was removed after burr holes were drilled and craniotomy performed to connect the two holes allowing further irrigation and removal, then we have changed our root operation to Extirpation (taking or cutting out solid matter from a body part) and our approach to open (craniotomy).  The ICD-10-PCS code will now be 00C40ZZ.

Once you are able to determine the root operation, you can review the operative report for the information that will lead to the appropriate approach.  If you still have questions, the 3rd Qtr. 2015 Coding Clinic, pages 10-13, has other scenarios and rationale related to SDH evacuation procedures which would be helpful to review.   

Now you are In the kNOW!!

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.