My physician is stating we should bill 61510 and 61518 because of two separate craniotomy incisions. However, i billed 61518 w/22 mod. Any thoughts or guidelines you guys can direct me to? What are your thoughts?
DESCRIPTION OF THE PROCEDURE:
The patient was brought to the operating room and underwent general endotracheal
anesthesia in the supine position. He was positioned in 3/4 prone with an axillary roll.
His head was turned to the right side and splinted on the Mayfield headholder and
underwent coregistration using the navigation system. The linear incision from before was
marked and navigation was used to locate the lesion along the suboccipital area. The
transverse sinus was delineated as well as the sigmoid sinus and a primary incision was
marked. Subsequently, he received preoperative antibiotics, mannitol, Keppra and steroids
for brain relaxation. A 10 blade was used. The skin was opened subcutaneously and the
musculature was reflected off of the suboccipital bone all the way to the foramen magnum.
Subsequently, self-retraining retractors were placed. A suboccipital craniotomy was
performed and subsequently this was enlarged to expose the whole length of the transverse
sinus. The operating microscope was brought into the field. The dura was opened and
reflected superiorly and a supracerebellar approach was performed. We appreciated
paramedian bridging vein, which was preserved. Otherwise, we had a good corridor.
Ultrasonography was performed and identified the lesion in relationship to the distance to
the surface. We then developed the supracerebellar corridor and the edge of the tentorium
was appreciated and with anatomical landmarks, we then found the lesion of the pia of the
tentorial surface of the cerebellum. This was incised. A small corticectomy was made.
This was confirmed with navigation and subsequently we encountered a mass that appeared
necrotic in nature. This was cored out using a Sonopet circumferentially. The brain was
quite relaxed. We also opened the cisterna magna prior to doing this to further mobilize
the cerebellum. Subsequently, the ultrasonography confirmed gross total resection. The
dura was closed watertight and expanded with a muscle graft. Tisseel was used to
reinforce. Compressed Gelfoam and dura matrix was placed. The bone was plated with a
mesh cranioplasty. A mesh cranioplasty greater than 5 cm was also performed as most of
the bone was craniectomized. Subsequently, the musculature was closed with 2-0 Vicryl
stitches and the subcutaneous tissues in the same fashion and running nylon for the skin.
Bacitracin ointment, Telfa and sterile dressing was applied. Subsequently, we turned our
attention to the left occipital area. The prior incision was marked. The 10 blade was
used. The skin was opened down to the bone. Periosteal elevator was reflected from the
prior plates and craniotomy. The titanium plates and screws were removed and subsequently
we opened, reflected the dura towards the midline sinus. There was nodular disease
attached to the falx. Using the operating microscope, ultrasonography showed the evidence
of the echogenicity. Using bipolar we circumferentially detached this big lump of
necrotic tissue associated with tumor and detached it from the pia of the tentorium. We
entered the opening of the ventricle and this was the end of the resection. Gelfoam was
used to plug the ventricle and subsequently Nu-Knit was used for the cavity. The dura was
closed loosely as it was quite deteriorated. Subsequently a DuraMatrix graft was placed.
Compressed Gelfoam. The bone was plated with titanium screws in place. The galea was
closed with 2-0 Vicryl, the skin with running nylon. Bacitracin ointment, Telfa sterile
dressing was applied. I was present and scrubbed for both operations entirely. Needle
and sponge counts were correct. There were no complications. Patient extubated,
transferred to the PACU in stable condition.
DESCRIPTION OF THE PROCEDURE:
The patient was brought to the operating room and underwent general endotracheal
anesthesia in the supine position. He was positioned in 3/4 prone with an axillary roll.
His head was turned to the right side and splinted on the Mayfield headholder and
underwent coregistration using the navigation system. The linear incision from before was
marked and navigation was used to locate the lesion along the suboccipital area. The
transverse sinus was delineated as well as the sigmoid sinus and a primary incision was
marked. Subsequently, he received preoperative antibiotics, mannitol, Keppra and steroids
for brain relaxation. A 10 blade was used. The skin was opened subcutaneously and the
musculature was reflected off of the suboccipital bone all the way to the foramen magnum.
Subsequently, self-retraining retractors were placed. A suboccipital craniotomy was
performed and subsequently this was enlarged to expose the whole length of the transverse
sinus. The operating microscope was brought into the field. The dura was opened and
reflected superiorly and a supracerebellar approach was performed. We appreciated
paramedian bridging vein, which was preserved. Otherwise, we had a good corridor.
Ultrasonography was performed and identified the lesion in relationship to the distance to
the surface. We then developed the supracerebellar corridor and the edge of the tentorium
was appreciated and with anatomical landmarks, we then found the lesion of the pia of the
tentorial surface of the cerebellum. This was incised. A small corticectomy was made.
This was confirmed with navigation and subsequently we encountered a mass that appeared
necrotic in nature. This was cored out using a Sonopet circumferentially. The brain was
quite relaxed. We also opened the cisterna magna prior to doing this to further mobilize
the cerebellum. Subsequently, the ultrasonography confirmed gross total resection. The
dura was closed watertight and expanded with a muscle graft. Tisseel was used to
reinforce. Compressed Gelfoam and dura matrix was placed. The bone was plated with a
mesh cranioplasty. A mesh cranioplasty greater than 5 cm was also performed as most of
the bone was craniectomized. Subsequently, the musculature was closed with 2-0 Vicryl
stitches and the subcutaneous tissues in the same fashion and running nylon for the skin.
Bacitracin ointment, Telfa and sterile dressing was applied. Subsequently, we turned our
attention to the left occipital area. The prior incision was marked. The 10 blade was
used. The skin was opened down to the bone. Periosteal elevator was reflected from the
prior plates and craniotomy. The titanium plates and screws were removed and subsequently
we opened, reflected the dura towards the midline sinus. There was nodular disease
attached to the falx. Using the operating microscope, ultrasonography showed the evidence
of the echogenicity. Using bipolar we circumferentially detached this big lump of
necrotic tissue associated with tumor and detached it from the pia of the tentorium. We
entered the opening of the ventricle and this was the end of the resection. Gelfoam was
used to plug the ventricle and subsequently Nu-Knit was used for the cavity. The dura was
closed loosely as it was quite deteriorated. Subsequently a DuraMatrix graft was placed.
Compressed Gelfoam. The bone was plated with titanium screws in place. The galea was
closed with 2-0 Vicryl, the skin with running nylon. Bacitracin ointment, Telfa sterile
dressing was applied. I was present and scrubbed for both operations entirely. Needle
and sponge counts were correct. There were no complications. Patient extubated,
transferred to the PACU in stable condition.