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Dermal Sinus Tract with communication with sagittal sinus at vertex

Christopher Posted Tue 22nd of January, 2019 08:26:49 AM
Will you please help me code this? Post Op Dx: Angioma at the vertex, communication with sagittal sinus Pre Op Dx: Dermal sinus tract with communication with sagittal sinus at vertex He was placed in Mayfield pins and positioned supine on the operation table with his head flexed. The region of the defect over the vertex was prepped and draped in standard fashion. A horseshoe shaped incision was made around the lesion and carried down to the periosteum. The patient’s scalp was too thick to place Raney Clips. The Bovie and bipolar were used as needed for hemostasis. The scalp flap was reflected with fish hooks. The Bovie was used to dissect down to the defect in the skull. A tract could be seen lading from the sagittal sinus, extending up into the scalp. The patient had a firm area, in a somewhat more boggy area as well associated with that that could be palpated through the scalp. A 2-0 silk ligature were passed around the communication with the sagittal sinus and the stalk was then divided. The dissection was followed towards the scalp. The patient was found to have a dermal sinus tract with a small associated cyst. This extended up to the skin. To avoid recurrence, the actual cyst was excised with some of the scalp. The Midas Rex was then used to drill around the track that extend intracranial, and it was followed to the dura. Once the dura was exposed, overlying the sinus, a bit of bleeding was encountered. Another silk ligature was used to tie off the tract where it entered the sinus. The previously ligated section was resected and removed. Copious amount of warm irrigation was used throughout the procedure as needed. A large piece of Gelfoam was used to control bleeding from the sinus. A burr hole was selected and secured to the skull with 4 mm screws. The wound was irrigated copiously with antibiotic solution. A gram of vancomycin powder placed over the skill. The wound was then closed with 2-0 vicryl was used to reapproximate the Galea. The patient had the horseshoe shaped incision was closed in that used to excise the cyst associated with the dermal tract. Staples were used to close the skin.
SuperCoder Answered Wed 23rd of January, 2019 04:46:45 AM

AAE does not provide coding for operative reports and chart notes.

SuperCoder offers SuperCoding on Demand (SOD) ( for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail for more information.

Christopher Posted Wed 23rd of January, 2019 05:06:15 AM
You make it really easy to decide in the future if I will ever use Supercoder again. The answer at this point is no.
SuperCoder Answered Thu 24th of January, 2019 03:03:25 AM

Hi Christopher,

Greeting from SuperCoder. Hope you are doing good.

Just to put it in your kind notice, that this platform is only for "Ask An Expert" query, whereas you sent the op-report to code. Kindly send us this report through SuperCoding on Demand (SOD), we definitely will provide you the resolution. This is our defined channel and we are bound to follow the process. Please contact (866)228-9252 or e-mail, and mention to send the op-report to medical coding team. We will respond you accordingly.


SuperCoder AAE Team

Christopher Posted Fri 25th of January, 2019 09:55:43 AM
And yet, my question was not answered and at the same time you still keep my money and don't give the opportunity to ask a different question in the future. Why would I contact you or submit another question to a different portion of the same website with no guarantee that my question would be answered and if it wasn't, id lose my money again. Can you see why I would be annoyed?
SuperCoder Answered Mon 28th of January, 2019 02:01:59 AM

Hi Christopher,

Greeting from SuperCoder. Hope you are doing good.

We have received your op-report through the SuperCoding on Demand (SOD), we are working on this and will get back to you with proper coding.

We consider you as our valued customers, this time we will not charge anything extra from you, but going forward kindly send op-report to the "SuperCoding on Demand (SOD)".

Happy working.

SuperCoder Team

SuperCoder Answered Tue 29th of January, 2019 10:00:06 AM

Hi Christopher,

Greeting from SuperCoder. Thank you for your patience.

After thorough research, as per provided documentation, the performed procedure is not represented by any of the standard and active CPT codes available. It is suggested to bill the report with the CPT 64999 (Unlisted procedure, nervous system) and ICD D18.01. Also, when reporting a procedure with an unlisted code, submit a cover letter explaining the reason for choosing the unlisted code instead of a defined, active code. Also include the operative notes or other relevant documentation to strengthen the claim and to avoid a possible denial. Your payer will consider claims with unlisted procedure codes on a case by case basis, and they will determine payment based on the documentation you provide.

Happy working.

SuperCoder Team

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