# Crani Case



## RebeccaWoodward* (Jul 31, 2009)

Preop dx-

1-multiple facial and skull fractures
2-Rt frontotemporopatietal epidural or subdural hematoma w/ severe mass effect & midline shift
3-Traumatic brain injury w/ rapidly declining neurological status

Procedure-
1-Rt. Frontotemporopatietal craniotomy
2-Evacuation of rt frontotemporoparietal epidural hematoma
3-Insertion of intracranial pressure monitor
4-Stabilization & fixation of multiple skull fx & bone fragments

A skin incision was made and Raney clips were applied to the skin edges for hemostasis.  The scalp flap was reflected anteriorly.  The temporalis muscle was reflected separately and reflected anteriorly and inferiorly.  As the scalp and muscle flaps were reflected it was apparent the patient had multiple skull fractures.  A high speed drill was used to place 3 bur holes and the craniotome was used to create a craniotomy on the right side.  Two separate bone fragments were removed and placed on the back table for later use.  As the bone pieces were removed, a large amount of epidural acute hemorrhage was encountered.  It was 3 cm thick at middle meningeal artery.  Initially, the bleeding was controlled w/ pressure.  Coagulation was ineffective in controlling the bleeding.  Therefore, a 4-0 Nurolon suture was placed circumferentially around the bleeding artery in the dura and the artery was tied off.  There are other numerous places along the dura which were bleeding, at a less brisk pace.  These points were controlled w/ bipolar cautery, surgical and gelfoam.  The dura was tacked up to the inner table at multiple points, to decrease the size of the epidural space and to control bleeding.

Once the epidural hematoma had been removed, the brain had been decompressed and the major bleeding points were controlled, the dura was opened sharply and inspection of the subdural space was carried out.  There was no evidence of subdural hematoma, but there was subarachnoid hemorrhage present.  An intracranial pressure monitor was placed and brought out through a separate skin exit site.  It was secured to the skin using a 3-0 silk suture.  The dura was closed using running 4-0 Nurolon suture.  A 10-French flat JP drain was placed in the epidural space and brought out through a separate skin exit site.  

Attention was then turned to the skull fractures and bone fragments.  Several of the bone fragments were still attached but unstable.  They were stabilized w/ Codman mini plates & screws for fixation.  The two bone fragments that had been removed were attached to each other and then to the remainder of the skull using Codman mini plates & screws…………

I'm looking at 61312 62005-51 and 61210(questionable)

All comments are welcomed!


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## lmbroomall (Jul 31, 2009)

I came up with the same codes, including the 61210. Very interesting case compared to what I have all day.


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## RebeccaWoodward* (Jul 31, 2009)

Thanks for your feedback!  I really appreciate it.


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## FTessaBartels (Aug 3, 2009)

*61210 bundles*

61210 bundles with 61312

The way I read this the burr holes were drilled to allow for the craniotomy. Once the skull fragments had been removed the ICP monitor could be inserted. 

I would not code the 61210.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## RebeccaWoodward* (Aug 3, 2009)

I was hoping you were going to comment on this, Tessa.  I know that you have some experience in this area. I tend to agree that 61210 may be inclusive.  My surgeon doesn't necessarily agree with this.  I'm still looking for that sealing document of proof that indicates one way or the other.  I find that crani info can be hard to come by.  Thanks again!


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