Subdural Hematoma Evacuation

CPT 61312
Approach Open
Add-on / Variant CPTs
  • 61313 — Craniotomy for evacuation of subdural hematoma, infratentorial
  • 61314 — Burr hole for subdural hematoma
  • 61315 — Subdural taps through fontanelle, infant
Preoperative Diagnosis:

[Acute / subacute / chronic] subdural hematoma, [right / left] [with / without] midline shift

Postoperative Diagnosis:

Same

Procedure Performed:

[Craniotomy / Burr hole trephination] for evacuation of [acute / chronic] subdural hematoma

Attending Surgeon:

[Attending name], MD

First Assistant:

[Resident/Fellow/PA name]

Anesthesia:

General endotracheal
Patient supine, head turned away from operative side. Head secured in Mayfield pins [or horseshoe].

Indications:

Patient presents with [altered mental status / focal neurological deficit / progressive headache / declining GCS] in the setting of [traumatic / spontaneous / anticoagulation-associated] [acute / chronic] subdural hematoma. CT head demonstrates [X] mm hematoma with [X] mm midline shift and [effacement of sulci / uncal herniation]. Emergent surgical evacuation indicated. Family / patient counseled on risks including death, stroke, reaccumulation, and neurological deficit.

Findings:

[Acute / chronic / mixed] subdural hematoma. [Hyperdense / hypodense / mixed density] on CT. Brain [returned to midline / remained shifted] after evacuation. Underlying cortex [normal / edematous / contused].

Description of Procedure:

The patient was taken emergently to the operating room, positioned supine with head turned to the [contralateral] side and secured in Mayfield pins. The scalp was prepped and draped in sterile fashion.
[For craniotomy:] A large [frontoparietal / temporoparietal] question-mark or linear incision was made. Periosteum elevated. A [5 x 4] cm craniotomy was fashioned. Dura was under tension. The dura was opened in a curvilinear fashion with controlled decompression. [Acute / chronic] subdural hematoma evacuated with suction and irrigation. The hematoma was [liquid / gelatinous / organized]. Cortical surface inspected. Hemostasis achieved with bipolar and Gelfoam. Brain relaxed and pulsatile at closure.
[For burr hole trephination (chronic SDH):] Two burr holes placed frontally and parietally. Dura and outer membrane incised. [Brown-liquefied] chronic hematoma evacuated by irrigation with warm saline. [A subdural drain was placed through the posterior burr hole and tunneled for 48-hour drainage.]
Dura closed [watertight / with onlay patch]. Bone flap replaced and secured with titanium plates. Galea and skin closed. Patient tolerated the procedure well.

Complications:

None

Specimens:

[Subdural membrane sent to pathology / Hematoma discarded]

Estimated Blood Loss:

[X] mL

Drains:

[Subdural drain to gravity drainage / ICP monitor placed / None]

Disposition:

Patient taken to neurosurgical ICU in [stable / critical] condition.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: [Acute / subacute / chronic] subdural hematoma, [right / left], with *** mm midline shift
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: [Craniotomy / Burr hole trephination] for evacuation of [acute / chronic] subdural hematoma, [right / left]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: General endotracheal

INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting with [altered mental status / declining GCS / focal neurological deficit] in the setting of a [traumatic / spontaneous / anticoagulation-associated] [acute / chronic] subdural hematoma. CT head demonstrates *** mm hematoma with *** mm midline shift and sulcal effacement. [Anticoagulation reversed preoperatively.] Emergent surgical evacuation indicated. Risks including death, stroke, reaccumulation, and neurological deficit were discussed with family. Informed consent obtained.

FINDINGS: [Acute / chronic / mixed] subdural hematoma. Consistency: [clot / gelatinous / brown liquid with membranes]. Brain [returned to midline / remained shifted] after evacuation. Underlying cortex [normal / edematous / contused].

DESCRIPTION OF PROCEDURE:
Patient taken emergently to the OR, positioned supine with head turned contralateral and secured in Mayfield pins. Scalp prepped in sterile fashion. [CRANIOTOMY: Frontoparietal question-mark incision; *** × *** cm craniotomy fashioned; dura under tension; dura opened in curvilinear fashion with controlled decompression; [acute / chronic] hematoma evacuated with suction and irrigation; cortex inspected; hemostasis with bipolar and Gelfoam; brain relaxed and pulsatile at closure; dura closed watertight; bone flap replaced with titanium plates.] [BURR HOLES (chronic SDH): Two burr holes placed frontally and parietally; dura and outer membrane incised; brown liquefied chronic hematoma evacuated by irrigation with warm saline; subdural drain placed through posterior burr hole and tunneled.] Galea and skin closed in layers. Patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: *** mL
SPECIMENS: [Subdural membrane to pathology / Hematoma discarded]
COMPLICATIONS: None
DRAINS: [Subdural drain to gravity drainage / ICP monitor placed / None]
DISPOSITION: Patient taken to neurosurgical ICU in [stable / critical] condition.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Burr hole for chronic SDH

Preferred for thin liquid chronic SDH. CPT 61314. Document two burr holes, irrigation with warm saline, drain placement, and hematoma consistency.

Bedside twist drill craniostomy

For liquefied chronic SDH in high-risk patients. Document bedside procedure, drain placement, and output.

Decompressive craniectomy

For malignant cerebral edema after SDH evacuation. Remove bone flap and store. Document duraplasty with patch. CPT 61322.

Charting Tips
  • Document hematoma consistency: acute (clot), subacute (motor oil), chronic (brown liquid, membranes)
  • State pre- and post-evacuation brain relaxation
  • Note any underlying contusion, cerebral laceration, or bridging vein
  • For chronic SDH: document drain placement and planned removal at 48h
  • Document reversal of anticoagulation/antiplatelet preoperatively
  • ICP monitor placement if brain edematous at closure
Billing Tips
  • Bill 61312 for craniotomy for evacuation of subdural hematoma, initial (29.42 wRVU, 90-day global). Bill 61313 for intracranial hematoma evacuation (27.39 wRVU). Bill 61314 for infratentorial subdural hematoma (25.25 wRVU).
  • For burr hole drainage of chronic subdural hematoma, bill 61154 (14.22 wRVU) for a single burr hole or 61156 (16.51 wRVU) for twist drill/trephination. Do not use craniotomy codes (61312) for burr hole procedures. The approach determines the code.
  • Subdural drain placement at the time of burr hole is bundled into 61154/61156. Do not separately bill drain placement. Document drain size, placement depth, and initial output.
  • 90-day global period: CT surveillance, drain removal, and clinic follow-up are bundled. Re-operation for reaccumulation within the global period requires modifier -78.
  • Postoperative seizure prophylaxis, anticoagulation reversal decisions, and GCS monitoring are documented in the ICU notes and do not generate separate surgical procedure fees. Document them for medicolegal completeness.