# Cranioplasty DISAGREEMENT! Help!



## marci_ann (Mar 29, 2013)

Hi! My surgeon did a cranioplasty (greater than 5cm skull defect) but he also put in a custom made plate so for this procedure I used 62141 for the cranioplasty and 62143 for the plate. One coder agrees with me, one says it wouldn't be appropriate. Another coder asked what the full description of the cranioplasty was to know whether or not the plate would be included and I wasn't sure. So hoping somebody can take a look at this for me and tell me what they think. 

PROCEDURE:  Left frontotemporoparietal cranioplasty using custom made PEEK skull

prosthesis.

ANESTHESIA:  General.

INDICATIONS:  This 52-year-old woman had a severe head injury in October 2012,

requiring emergency left frontotemporoparietal craniotomy to evacuate acute

subdural hematoma.  For a variety of reasons explained in the original operative

note, the skull flap was left out, but could not be lodged in her abdomen,

requiring the present need for a custom prosthesis.

FINDINGS:  The scalp was more robust and vascular than we had feared; we

obtained a good scalp elevation without CSF leak; the PEEK plate fit absolutely

perfectly into the defect; we were surprised how little we had to mobilize the

scalp to obtain coverage; and our closure of the scalp was surprisingly under

only modest tension.

DESCRIPTION OF PROCEDURE:  After identification in the operating room, the

patient underwent a general anesthetic with endotracheal intubation, and was

placed supine with a roll behind the left shoulder, and head turned to the

right.  We clipped all her scalp hair, and spent considerable time decreasing

the scalp with alcohol and oil.  After this, she underwent a standard prep and

drape of the left side of her head.

We made an incision following the previous incision line, starting in the

frontal region, going backwards around the parietal boss, then forwards, in the

shape of a?, with the stem just in front of the left ear.  We purposely did

minimal hemostasis of the scalp, since we wanted to recruit as much vascular

supply for healing as possible.  The scalp was more robust and vascular than

expected, suggesting good healing.  We used a knife to go through periosteum,

and periosteal elevators to deflect the flap to the outside of the craniectomy

to a distance of approximately 3-cm to mobilize the scalp for later closure.  We

were unsure if this would be enough, but this seemed a modest amount that might

suffice.

We then developed a plane between the dura (with occasional scarring due to Gel-

Foam) internally at the periosteum externally, with occasional dense adhesion

points, which were released with Metzenbaum scissors.  We worked very slowly,

mainly by gently pulling on the flap and separating it from the underlying dura

with closed scissors, Penfield dissectors, and at times the fingers, in the most

gentle manner that we could.  We did see a small gap in the dura in the

anteromedial corner of the opening, but there was no CSF leak whatsoever.  With

this, we were able to retract the scalp flap anterolaterally, leaving a bit of

attachment in the extreme lateral portion of the temporalis muscle, which we

avoided transecting as much as possible.  The scalp flap was retained on

fishhooks, with moist laps covering the flap and a rolled moist lap behind the

scalp to avoid hyperextension and ischemia.

We took the PEEK custom plate and placed it on the skull defect, where it fit

absolutely perfectly.  There was no need to dissect any more along the edges of

the bones, and an area of craniectomy further laterally was left as it was

without further dissection, and need not be further explored.  The brain had

filled much of the space, such that we did not feel tenting sutures were

necessary in this case.

Being satisfied with the PEEK plate and with the skull defects fitting

perfectly, we put some sheets of Surgicel on the dura and placed the prosthesis

exactly in the defect.  It was attached to the surrounding bone using 3 square

Leibinger plates, one anteriorly, one in the midportion (parietal boss), and one

in the posterior temporal region just behind the ear.  Application was easy and

everything came together in a very satisfactory matter.

The wound was copiously irrigated with antibiotic solution.  This included

irrigation through the holes in the plate of the space under the plate.  We then

began to close.

I should note that there was no need for further immobilization of the scalp,

since the scalp came together very nicely, more easily than we had feared it

would.

I should also note that there was essentially no temporalis fascia to close,

since it was threaded and thin.

The wound was closed with inverted interrupted 3-0 Vicryl for the galea,

followed by staples for skin, more closely approximated than usual given the

worries about the scalp.  Antibiotic ointment and a standard dressing were

applied.

There were no intraoperative complications of note, and at the time of this

dictation, the patient has yet to be awaken from anesthetic.


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## CVR (Apr 2, 2013)

I believe the 61241 includes the plate:

61241:The physician corrects a defect in the cranium. In 62140, the defect is less than 5 cm. In 62141, the defect is greater than 5 cm. The physician incises and retracts the scalp. The bone flaps are lifted and remodeled. A prosthesis may be used to reapproximate the bony edges. The skull is stabilized and the scalp is reapproximated and sutured in layers.


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