Neurosurgery Coding Alert

Hint: Confirm spinal decompression, check documentation for any additional procedures. In a patient with Chiari malformation and showing symptoms of cerebellar tonsillar herniaiton, your surgeon may plan a suboccipital craniectomy decompression of the medulla and spinal cord with lysis of adhesions and C1 soft tissue decompression for Chiari malformation. In the operative note, you need to confirm the decompression and check for any additional procedures. Let the examples that follow guide you to smooth claims for these procedures. Confirm Suboccipital Craniectomy Take a look at the sample operative note that describes decompression for Chiari malformation: "After prophylactic preoperative antibiotics, intubation and catheterization, a Mayfield head clamp was applied. The patient was then turned prone while maintaining traction. With standard aseptic precautions, an incision was made from the occipital protuberance to the level of C2. Bipolar and Bovie electrocautery was used for hemostasis. Dissection was done in the midline fascial plane. [...]