# Nuero-surgery



## lori85210 (Nov 10, 2009)

Please help me code the placement of bone flaps into the abd subcutaneous compartment or a code that comes close to it.  I'm going to use and unlisted code for this portion of the surgery, but need a code description that comes close to it where I can change a few words and I will have my description for the unlisted code to send to my finance person to compare pricing.  Thanks in advance for all your help in advance, here is the operative report:

POSTOPERATIVE DIAGNOSIS:  Malignant intracranial hypertension.

PROCEDURE PERFORMED:
 1.  Bilateral decompressive craniectomy with stellate opening of the dura.
2.    Revision of right external ventricular drain.
3.    Placement of bone flaps into the abdominal subcutaneous compartment.

OPERATIVE FINDINGS:  Pressure was significantly lower at the end of the
case.

COMPLICATIONS:  A 1-cm corticectomy was made in the right frontal cortex
upon opening the dura.

ESTIMATED BLOOD LOSS:  300 mL.

INDICATIONS FOR PROCEDURE:  This 10-year-old male had undergone a
spontaneous intraventricular hemorrhage with hydrocephalus secondary to an
arteriovenous malformation rupture 72 hours previously.  Despite maximal
aggressive medical management, his intracranial pressure continued to rise
into the upper 30s and 40s.  Emergency surgery to attempt to decompress the
brain and brainstem was discussed at length with his mother.  The risks of
the decompressive craniectomy including death, infection, life-threatening
bleeding, transfusion, damage to the brain, need for further surgery, and
infection were discussed.  She appeared to understand the procedure and
risks and provided consent for surgery.

PROCEDURE:  The patient was brought emergently to the operating room.  His
head was placed on horseshoe headrest in the supine position.  I then
shaved, prepped and draped in the usual fashion after tying off the
external ventricular drains, cutting the distal catheters, and discarding
those.

I made a bicoronal scalp incision and secured the edges with Raney clips.
The scalp was reflected anteriorly toward the frontal bone.  The
ventriculostomy catheters were brought back through the scalp into direct
vision.  No drainage was noted out of the right ventricular catheter.
Spontaneous pearly hemorrhagic spinal fluid was draining freely out of the
left catheter.

I made a bur hole 2.5 cm to the right of midline.  The dura was stripped
off the undersurface of the bone.  A cranial router was then used to
outline a large frontal parietal temporal bone flap leaving a tongue of
bone on the right for the ventriculostomy catheter.

I turned my attention to the left.  Again, a single bur hole was made
approximately 2.5 cm off of the midline.  A small amount of venous bleeding
was noted through the bur hole.  This could not easily be controlled with
bone wax.  The dura was stripped from the undersurface of the bone.  Again,
the cranial router was used to outline a large frontal parietal temporal
bone flap.  Both bone flaps were elevated and the underlying dura stripped.
Bone flaps were set aside in bacitracin-soaked laparotomy sponges.

The right ventricular catheter was not draining.  This was removed and
replaced with a new Bactiseal ventricular catheter.

I then opened a 15-cm transverse skin incision in the right upper quadrant.
This was carried down to the anterior rectus sheath.  A large subcutaneous
pocket was then created.  The pocket was irrigated with bacitracin saline
followed by Betadine saline.  The bone flaps were nestled together and then
passed into the pocket.  The Hemovac drain was placed underneath the bone
flaps and brought out through a separate stab incision in the skin.  This
was connected to the drainage bulb.  The incision was then closed in layers
with interrupted Vicryl followed by running Monocryl for skin.  A retention
suture was placed at the drain site.

The dura was elevated in the right frontal region and sharply incised.
Cottonoids were used to protect the brain from the dural splinting
incisions.  It was noted after the dura was opened that a 1-cm corticectomy
had been made in one of the right middle frontal gyri.  The cortical veins,
which were dark blue and showing evidence of stasis as well as the
arteries, which were sluggishly pulsatile prior to dural opening became
bounding after dural opening.  Duragen was then placed over the exposed
brain.

The venous lacune, which was identified on the left side, was controlled
with Gelfoam, thrombin spray and gentle pressure.  The left hemisphere dura
was elevated, sharply incised and opened in a stellate fashion widely.
Duragen was placed over the exposed brain.  The scalp was reflected and the
external ventricular drain was brought out through the stab incisions in
the scalp.  They were attached to their connectors.  The catheters and
connectors were secured to the scalp and to each other with silk ties and
with nylon suture.  A Hemovac drain was placed over the midline bone.  It
was secured to the scalp with a Vicryl suture.  The scalp was then
reapproximated with interrupted Vicryl followed by a running nylon skin
suture.  Antibiotic ointment and clean dressings were applied.  A retention
suture was placed to the drain.  The external ventricular drains were set
up.  The suction balls were attached to each of the abdominal and cranial
drains.  Antibiotic ointment and clean dressings were applied.  The drapes
were removed.  He was then moved to the ICU bed and taken to the ICU in
critical condition.  Needle and sponge counts were correct at the end of
the case.  Estimated blood loss was 300 cc.


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## RebeccaWoodward* (Nov 11, 2009)

*Look at 61316*...This is an "add on" code.  What code did you select for "Bilateral decompressive craniectomy with stellate opening of the dura"?
61322?

The retrieval of the grafts will be 62148


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## lori85210 (Nov 20, 2009)

So far I have 61322, 61322-50, 62225-51 and my last is the one on "creation of subcutaneous cavity in abd wall with implatation of cranial bone flaps" which I have not found a code for.  But I will look into the code you suggested.  Thanks.


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## FTessaBartels (Nov 20, 2009)

*Unlisted*

I think you will need to use an unlisted code, 17999.

What the surgeon is doing is creating a pocket in the subcutaneous abdominal wall so that the bone flaps he removed to relieve the intracranial pressure can be preserved for later replacement. 

I would consider this procedure (creating the subq pocket) akin to placing a tissue expander, CPT 11960 (work RVU 11.01)

Check with your surgeon to be sure s/he thinks that procedure/pricing is in line with what s/he actually did. 

Hope that helps (Hope the patient is okay, too).

F Tessa Bartels, CPC, CEMC


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