Linh Posted Wed 30th of December, 2015 18:35:04 PM
How would you code the following? One surgeon is performing the entire procedure. 61512 and 69990?
Indication: history of progressive visual loss. A MRI revealed findings of a large anterior skull base tumor, likely meningioma.
A bicoronal incision was made with care taken to preserve the pericranium. This was reflected anteriorly and held in place with fish hooks. The pericranial flap was then elevated separately. Burr holes when then placed in bilateral key holes as paracentrally. A modified bifrontal cranitomy was performed with a right sided temporal extension after division of the temporalis. The bone flap was elevated and the dura was seen as intact. The frontal sinus was entered and exenterated with removal of the posterior tble with a drill. The dura was tacked up circumferentially and then extradural dissection of the skull base was carried out with delivery of the tumor from the ehtmoid sinus. These sinuses were also exterated. The dural was then opened and the antrior superior saggital sinus ligated and cut with 2'o silk suture therre was immdiate tumor visiualied and prompt debulking and devascularisation was carried out. Extracapsulr dissection was carried out with preservation of enpassage vessels using microsurgery techniques. Once adequate debulking was achieved grossly, the operative microscope was draped and bought into the field. Further debulking and resection was carried out under high field until bilateral optic nerves were seen along with carotid arterires and anterior cerebrals and chiasm. No gross tumor was visualised. A small feeding vessel from the anterior left pericallosal was acrificed as it coursed through the superior surface of the tumor.
The skull base origin of the tumor and dural was also coagulated and excisied. Hemostatis was then achieved and attention turned to repair. The ethmoid sinus was packed with harvested temporalis muslce and facisa and dura seal applied A split thickness bone graft was then attained from the cranium and used to seal the skull base. The dural was then closed with 4'0 neuralon and the pericranial graft placed along the skull base and sutured in place to the dura. Further duraseal was applied to the suture lines. The bone flap was then replaced with titanium plates and screws and the temporalis fascia reapporximated.
SuperCoder Answered Mon 04th of January, 2016 00:34:56 AM
AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail firstname.lastname@example.org for more information.