suzyqmacdo2002
New
I am fairly new to Neurosurgery coding, so please excuse me if I am asking a question that has previously been answered.
Our patient had right frontal craniotomy with resection of glioblastoma in Sept. 2015. She presented with wound dehiscence and infected skull flap in Jan. 2016, at which time it was decided to remove all of the hardware in the skull with complete removal of the bone flap. Patient was admitted on March 31 with increased cerebral edema, increased left-sided weakness, and recurrent brain mass.
My surgeon performed redo right frontal craniotomy for resection of brain mass through the already open skull. So my question is would I use 61512 with the modifier -52?
Op not reads as follows:
PRE-OP/POST-OP DX: Right frontal skull defect, right frontal brain mass concerning for recurrent glioblastoma, left-sided weakness, significant
cerebral edema.
PROCEDURE PERFORMED: Redo right frontal craniotomy for resection of brain mass, possible recurrent glioblastoma, right frontal synthetic
cranioplasty using a PEEK implant from Stryker, which was custom fit based on the patient's anatomy, use of intraoperative sterotactic navigation with Stryker.
TECHNIQUE: The patient brought to operating room #11 at XXXXXX Medical Center, general endotracheal anesthesia was induced. The patient was supine on the operating table, the head placed in a Mayfield head holder, slightly flexed. She was registered first with the stereotactic navigation. I marked out her previous incision, then extended it on each end to try to take some of the tension off of the scalp for the closure. We cleaned, prepped,
and draped the scalp in a sterile fashion. There was some scabbing material on the scalp wound that was removed. There was soft tissue exposed beneath the scalp in this area. There was no evidence of erythema or pus in this area. The scalp was very thin and avascular in the area.
A timeout was then performed before we opened the incision with a 10 blade scalpel. On the area where the necrotic tissue was, we formed in an ellipse with the knife around it, removing the necrotic tissue, then used a periosteal elevator to elevate the scalp from the skull. I used blunt dissection with Metzenbaum scissors to undercut the scalp to the galea and periosteum for quite an expanse through the forehead and then back into the occipital region, which we later used for the wound closure. Once we had opened the scalp, placed a self-retaining retractor. I then opened the dura with 11 blade scalpel and Metzenbaum scissors. Encountered the old cavity from the surgical resection, which looked pretty normal, was lined with Surgicel and some scar tissue along the edges. The anterior laterally there was a small module which I removed piecemeal with tumor
forceps and suction that we encountered more normal edematous white matter surrounding it. We sent this for frozen pathology which only showed necrosis initially. We did send the remaining portion of the mass for permanent pathology. Once we did remove the mass, obtained hemostasis with bipolar cauterization, lined the cavity with Surgicel. Then closed the dura with interrupted 4-0 Nurolon sutures, covered this with a small piece of Gelfoam and placed the PEEK implants from Stryker over the cranial defect, securing it with the low profile cranial plating system.
At that point, we turned our attention to the closure of the scalp, which was still under some tension as it had contracted from the previous skull flap removal as well as the extensive radiation to the scalp. We debrided the edges of the scalp to get bleeding tissue, then closed the scalp with interrupted 2-0 nylon through the galea and subcutaneous tissues with a vertical mattress manner. Did this as my assistant squeezed the scalp
closed to approximate the edges. We then placed a loose head wrap on the patient.
She was transferred to the recovery room in stable condition. All needle and sponge counts were correct at the end of the case. The patient tolerated the procedure well. My assistant was present throughout the procedure and provided
visualization through retraction and suction. She also assisted with the superficial wound closure.
Thank you so much for any direction you can give me!
Our patient had right frontal craniotomy with resection of glioblastoma in Sept. 2015. She presented with wound dehiscence and infected skull flap in Jan. 2016, at which time it was decided to remove all of the hardware in the skull with complete removal of the bone flap. Patient was admitted on March 31 with increased cerebral edema, increased left-sided weakness, and recurrent brain mass.
My surgeon performed redo right frontal craniotomy for resection of brain mass through the already open skull. So my question is would I use 61512 with the modifier -52?
Op not reads as follows:
PRE-OP/POST-OP DX: Right frontal skull defect, right frontal brain mass concerning for recurrent glioblastoma, left-sided weakness, significant
cerebral edema.
PROCEDURE PERFORMED: Redo right frontal craniotomy for resection of brain mass, possible recurrent glioblastoma, right frontal synthetic
cranioplasty using a PEEK implant from Stryker, which was custom fit based on the patient's anatomy, use of intraoperative sterotactic navigation with Stryker.
TECHNIQUE: The patient brought to operating room #11 at XXXXXX Medical Center, general endotracheal anesthesia was induced. The patient was supine on the operating table, the head placed in a Mayfield head holder, slightly flexed. She was registered first with the stereotactic navigation. I marked out her previous incision, then extended it on each end to try to take some of the tension off of the scalp for the closure. We cleaned, prepped,
and draped the scalp in a sterile fashion. There was some scabbing material on the scalp wound that was removed. There was soft tissue exposed beneath the scalp in this area. There was no evidence of erythema or pus in this area. The scalp was very thin and avascular in the area.
A timeout was then performed before we opened the incision with a 10 blade scalpel. On the area where the necrotic tissue was, we formed in an ellipse with the knife around it, removing the necrotic tissue, then used a periosteal elevator to elevate the scalp from the skull. I used blunt dissection with Metzenbaum scissors to undercut the scalp to the galea and periosteum for quite an expanse through the forehead and then back into the occipital region, which we later used for the wound closure. Once we had opened the scalp, placed a self-retaining retractor. I then opened the dura with 11 blade scalpel and Metzenbaum scissors. Encountered the old cavity from the surgical resection, which looked pretty normal, was lined with Surgicel and some scar tissue along the edges. The anterior laterally there was a small module which I removed piecemeal with tumor
forceps and suction that we encountered more normal edematous white matter surrounding it. We sent this for frozen pathology which only showed necrosis initially. We did send the remaining portion of the mass for permanent pathology. Once we did remove the mass, obtained hemostasis with bipolar cauterization, lined the cavity with Surgicel. Then closed the dura with interrupted 4-0 Nurolon sutures, covered this with a small piece of Gelfoam and placed the PEEK implants from Stryker over the cranial defect, securing it with the low profile cranial plating system.
At that point, we turned our attention to the closure of the scalp, which was still under some tension as it had contracted from the previous skull flap removal as well as the extensive radiation to the scalp. We debrided the edges of the scalp to get bleeding tissue, then closed the scalp with interrupted 2-0 nylon through the galea and subcutaneous tissues with a vertical mattress manner. Did this as my assistant squeezed the scalp
closed to approximate the edges. We then placed a loose head wrap on the patient.
She was transferred to the recovery room in stable condition. All needle and sponge counts were correct at the end of the case. The patient tolerated the procedure well. My assistant was present throughout the procedure and provided
visualization through retraction and suction. She also assisted with the superficial wound closure.
Thank you so much for any direction you can give me!