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Arul karthik Answered Tue 06th of September, 2011 23:15:43 PM


OPERATIVE NOTE: The patient was brought to the operating room and
placed supine on the operating table. After adequate intravenous and
inhalational anesthesia had been achieved, she was administered
intravenous antibiotics and 200 mg of hydrocortisone.
Next, her head was placed in a three pin Mayfield clamp and slightly
turned to the right. Care was taken to assure all pressure points were
adequately padded and the table was placed in a reverse Trendelenburg
position. The BrainLAB system was registered to the patient and used
to plan or trajectory through the paranasal sinuses to the skull base.
The patient's nostrils were prepped and draped in the usual sterile
fashion. Additionally, abdomen was prepped and draped in the usual
sterile fashion. Her nostrils were then packed with oxymetazoline
soaked pledgets.
The oxymetazoline pledgets were removed and a 0 degree endoscope was
placed in the right nostril. The anatomy was inspected and in standard
fashion, the right middle turbinate was resected. Next, the sphenoid
ostium was visualized and this was opened using Tru-Cut rongeurs and
punches. The BrainLAB system was used to confirm our trajectory
through the paranasal sinuses to the skull base.
Next, a Freer elevator was used to incise the posterior aspect of
nasal septum along the junction of the bony septum. The bony septum
was then taken down with high speed drill, Tru-Cut rongeurs and
Kerrison punches. Next, we proceeded to open the face of the sphenoid
sinus widely. Blakesley forceps were used to take down the mucosa in
doing so, we had gained access to the skull base and visualized it
from one carotid to the other as well as from the ethmoid sinuses down
to the clivus.
Using a high speed drill, the midline skull base floor was drilled
out. The dura was then opened sharply with endoscopic knife and tumor
was encountered. Using endoscopic visualization, curettes and suction
the tumor was resected from the sella, suprasellar and parasellar
regions as well as the supraclinoid area and the cavernous sinuses
bilaterally. Once we had achieved a gross total resection, the dura
was closed with Tisseel. The wound was copiously irrigated out. Next,
a NasoPore dressing was placed in the right nostril and bacitracin
ointment was placed in both nostrils. A mustache dressing was
At the conclusion of the case, the sponge, instrument, and needle
counts were correct. Please note there was no evidence of CSF leak. In
addition, prior to removing the tumor and during the resection and
subsequent completion of the resection, the BrainLAB tool was used to
confirm the anatomic landmarks.

SuperCoder Answered Wed 07th of September, 2011 06:41:17 AM

The CPT code is - 62165


Arul karthik Answered Wed 07th of September, 2011 17:37:32 PM

Tumor was at the skull base ( resected from the sella, suprasellar and parasellar
regions as well as the supraclinoid area and the cavernous sinuses
bilaterally), not pituitary tumor.... what about 61608, but with endoscopic approach,transnasal. It this unlisted?

SuperCoder Answered Thu 08th of September, 2011 07:21:51 AM

61608 is open procedure, so can't be used for the above scenario.

Cavernous sinuses are situated at the both side of pituitary gland. Resection of cavernous sinus (for tumor) directly indicates the pituitary tumor.

supraclinoid area consist internal carotid artery which branches supply blood to the posterior pituitary Meningohypophyseal Artery) via cavernous sinuses. Again, resection of supraclinoid area means the resection of part of posterior pituitary.

Sella turcica is the cavity where pituitary sits. Resection of sella, infrasella and parasella is another indication of pituitary tumor.

Here you are correct that there is no clear documentation of "pituitary tumor", but the resection performed on the anatomical subpart of pituitary. This kind of op report also depends upon diagnosis and physician's plan for the procedure.

As per my opinion, 62165 is the most appropriate code for the above report. There is no problem in using 62165. Even due to lack of documentation of pituitary you may use unlisted neuroendoscopy code but in that case also you will need to provide nearest Px code (62165) along with operative report and unlisted code. here the unlisted code will lead to drastic decrease in payment or denial.

Hope this is helpful.


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