Subdural Hematoma Evacuation
6131261314wRVU: 25.25 — Alternative primary — infratentorial extradural or subdural hematoma evacuation (25.25 wRVU, 90-day global)61315wRVU: 28.91 — Alternative primary — craniectomy/craniotomy for infratentorial intracerebellar hematoma evacuation (28.91 wRVU, 90-day global) — NOT a subdural code; for intraparenchymal cerebellar bleeding only61313wRVU: 27.39 — Alternative primary — supratentorial intracerebral (intraparenchymal) hematoma evacuation (27.39 wRVU, 90-day global) — NOT for subdural hematoma; only when intraparenchymal blood is separately evacuated61322wRVU: 33.4 — Decompressive craniectomy without lobectomy (33.40 wRVU, 90-day global) — may be billed alongside 61312 if SDH evacuation and decompressive craniectomy are both performed61323wRVU: 34.18 — Decompressive craniectomy with lobectomy (34.18 wRVU, 90-day global)
[Acute / subacute / chronic] subdural hematoma, [right / left] [with / without] midline shift
Same
[Craniotomy / Burr hole trephination] for evacuation of [acute / chronic] subdural hematoma
[Attending name], MD
[Resident/Fellow/PA name]
General endotracheal
Patient presents with [altered mental status / focal neurological deficit / progressive headache / declining GCS] in the setting of [traumatic / spontaneous / anticoagulation-associated] [acute / subacute / chronic] subdural hematoma. CT head demonstrates [X] mm hematoma with [X] mm midline shift and [effacement of sulci / uncal herniation]. [Surgical criteria met: hematoma thickness >10 mm or midline shift >5 mm (Brain Trauma Foundation threshold) / comatose patient (GCS <9) with hematoma <10 mm and shift <5 mm but GCS decrease ≥2 points, ICP >20 mmHg, or fixed/asymmetric pupils.] [Anticoagulation reversed preoperatively with [4-factor PCC + vitamin K / andexanet alfa / idarucizumab / platelet transfusion + DDAVP].] Surgical evacuation indicated. Risks including death, reaccumulation, stroke, and neurological deficit discussed.
[Acute / chronic / mixed] subdural hematoma. [Hyperdense / hypodense / mixed density] on CT. Brain [returned to midline / remained shifted] after evacuation. Underlying cortex [normal / edematous / contused].
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 (reverse question-mark trauma flap) incision was made. Periosteum elevated. A large craniotomy ([10-12] cm diameter) 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 / clot]. Cortical surface inspected; [no underlying contusion / contusion at [location]]. 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.
None
[Subdural membrane sent to pathology / Hematoma discarded]
[X] mL
[Subdural drain to gravity drainage / ICP monitor placed / None]
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 / temporoparietal] question-mark (trauma flap) incision; large [10-12 cm] craniotomy fashioned; dura under tension; opened curvilinear with controlled decompression; [acute / chronic] hematoma evacuated with suction and irrigation; cortex inspected — [no underlying contusion / contusion at ***]; hemostasis with bipolar and Gelfoam; brain relaxed and pulsatile at closure; dura closed watertight; bone flap replaced with titanium plates.] [BURR HOLES (chronic SDH): [1 / 2] burr hole(s) placed [frontally / frontally and parietally]; dura and outer membrane incised; brown liquefied chronic hematoma evacuated by irrigation with warm saline until return clear; [subdural / subgaleal] drain placed through [posterior] burr hole and tunneled for [24 / 48]-hour drainage.] 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
.TODAYVariants
Burr hole for chronic SDH
Preferred for thin liquid chronic SDH. CPT 61154 (burr hole with evacuation/drainage, 16.64 wRVU, 90-day global). Single burr hole is non-inferior to double burr hole in randomized data (shorter OR time, equivalent recurrence). Document number of burr holes, location, warm saline irrigation until clear return, drain placement (subdural or subgaleal), and planned drain duration (24-48 hours — DRAIN TIME 2 trial, Lancet Neurology 2024 showed 24h non-inferior to 48h).
Middle meningeal artery embolization (MMAE) for chronic SDH
Adjunctive MMAE reduces 90-day recurrence from ~11% to ~4% when added to surgical evacuation (EMBOLISE trial, NEJM 2024, n=400). MMAE is also used as standalone treatment for asymptomatic or minimally symptomatic chronic SDH and as a bridge in anticoagulated patients. Billed by interventional neuroradiology (CPT 61626 + 75894); document if MMAE was planned or performed at the same admission.
Bedside twist drill craniostomy
For liquefied chronic SDH in high-risk patients not tolerating OR. Document bedside procedure, drain placement, and output. CPT 61154.
Decompressive craniectomy
For malignant cerebral edema after SDH evacuation. Remove bone flap and store (autologous cranioplasty planned). Document duraplasty with patch, brain relaxation at closure, and flap storage. CPT 61322 (without lobectomy, 33.40 wRVU) or 61323 (with lobectomy, 34.18 wRVU). 61312 (SDH evacuation) and 61322/61323 may both be reported if both are separately performed and documented.
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 (subdural vs. subgaleal), drain duration (24h or 48h — both supported by evidence; DRAIN TIME 2 trial showed 24h non-inferior), and hematoma consistency at evacuation
- Document reversal of anticoagulation/antiplatelet preoperatively
- ICP monitor placement if brain edematous at closure
Billing Tips
- Bill 61312 for craniotomy for evacuation of supratentorial extradural or subdural hematoma (29.42 wRVU, 90-day global). Bill 61314 for infratentorial extradural or subdural hematoma (25.25 wRVU). Bill 61313 (27.39 wRVU) for supratentorial intracerebral (intraparenchymal) hematoma — 61313 is NOT an alternative SDH code and should not be used for subdural blood.
- For burr hole drainage of chronic SDH, bill 61154 (16.64 wRVU, 90-day global) for burr hole with evacuation/drainage of extradural or subdural hematoma. 61156 (17.01 wRVU) is for burr hole aspiration of an intracerebral hematoma or cyst — it is NOT appropriate for chronic SDH. Subdural drain placement is bundled into 61154; do not separately bill drain placement. Document drain size, placement depth, and initial output.
- Decompressive craniectomy: bill 61322 (craniectomy without lobectomy, 33.40 wRVU) or 61323 (with lobectomy, 34.18 wRVU). If SDH evacuation is performed at the same time as decompressive craniectomy, 61312 and 61322/61323 may both be reported — document that the SDH evacuation and the decompressive craniectomy were separate, distinct components of the procedure.
- 90-day global period: CT surveillance, drain removal, and clinic follow-up are bundled. Re-operation for reaccumulation (expected, common) within the global period requires modifier -78. Modifier -78 does not reset the global period.
- Middle meningeal artery embolization (MMAE) for chronic/subacute SDH is billed by interventional neuroradiology (CPT 61626 + 75894). This does not affect the surgical CPT for the burr hole/craniotomy component, but document if MMAE was planned or performed as adjunct therapy.
General coding reference. Verify with your institution’s billing department before submitting claims.