# Cranial Fracture with dura repair



## KLS515 (Sep 8, 2009)

I have a trauma case where the patient has severe facial fracture and anterior skull base defect with dural tears.  I am using 62010 for the dura repair portion, wondering if modifier 22 would be appropriate to use since this is bilateral and multiple large tears.  With the titanium mesh used in the repair of the skull base defect, is this included or is there another code to use for this?  I also am stumped on the harvesting of the flap which was used by a Maxillofacial surgeon for his procedure. I understand "periosteal" to be the tissues around the bone, not actually a bone harvest.(?) This portion of the note reads:

The patient was repositioned for a supine position with three prong head
fixation.  After prepping and draping in the usual sterile fashion,
bicoronal skin incision was made.  A bifrontal periosteal flap was
harvested for later use.  Bur holes were made.  A bifrontal craniotomy was
performed.  Large Gelfoam strips were placed over the superior sagittal
sinus with good hemostasis.  After 40 cc of CSF drainage, satisfactory
brain relaxation was achieved.  Gentle elevation in extradural fashion of
bilateral frontal lobes was performed and held in position with a
Greenberg retractor system.  The posterior wall of the frontal sinus and the ethmoid bone were fractured and penetrated into the base of bilateral frontal lobe, resulting in large multiple dural tears.  The anterior and posterior edges of dural tears were identified and closed with Duraguard graft.  Significant
anterior skull base defect was repaired using a titanium mash.  The
patient tolerated the entire procedure without any apparent complications.

Thanks for helping me out with my many questions!


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## RebeccaWoodward* (Sep 8, 2009)

1) Does the entire documentation support modifier 22?  Did the physician indicate complications or any indication that this was over and beyond the norm?  If he/she has thorough documentation to warrant 22, it could be justified.

2) The harvesting of the flap..."A bifrontal periosteal flap was
harvested for later use. Bur holes were made. A bifrontal craniotomy was
performed."-I guess my question is...was the flap transferred back to the same site?

3) Titanium Mesh...My first thought was a cranioplasty (in addition to 62010) but then I discovered that a cranioplasty code is not assigned for replacing the bone flap after a surgical procedure (example, after a craniotomy bone flap replacement - titanium mesh plating system); which leads me to believe that this is inclusive to cpt code 62010.

Is there anyway you can post any additional information for this op note?

Does anyone else have any thoughts on this???


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## KLS515 (Sep 9, 2009)

Unfortunately there is not much to this note.  I posted the main part, there was a portion with a lumbar drain placed, I've got that.  The "periosteal flap" is actually called a bone flap by the Maxillofacial surgeon who "splits under irrigation" and it is used as "bony strut for nasal dorsum" and another part was "gently tucked along the interior cranial fossa".  I know I can only use what's documented by the neurosurgeon for the harvest, not the Maxillofacial notes.

My first thought was the titanium mesh was included in 62010, but I wanted to discuss with someone with more brain trauma coding experience.

Due to the lack of thorough documentation, I do agree that 22 is not supported.  If he had been more specific...  This case has frustrated me from the beginning! Perhaps I should contact the Neurosurgeon for clarification of this "periosteal flap".  Thanks for your help.


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