craniotomy

  1. J

    SCC excision forehead with bone removal for clear deep margin

    Coding for an outpatient hospital surgery dept... Does anyone have a suggestion on how to code a "frontal scalp SCC excision 5x4 with burring of the outer cortex of the skull"? From the Op Note:"...complicated history with multiple attempted excision by Mohs surgery and additionally has had...
  2. J

    Question Burr Hole or Craniotomy?

    I have a case of a subdural hematoma that was evacuated via a procedure in which, "A burr hole was made and a long craniotomy was fashioned using the drill. The bone was removed..." I understand that the approach is crucial in coding these types of procedures, and my initial inclination was to...
  3. danskangel313

    Coding Diagnosis Based on Procedure? Concussion vs Unspecified Intracranial Injury DX

    I'm coding a scenario in which the patient had a craniectomy due to a brain injury and the provider documented specifically that the patient had a diagnosis of "Concussion" (with loss of consciousness, 16 hrs). I'm being advised that I should be coding S06.9X4 for unspecified intracranial injury...
  4. danskangel313

    Coding Diagnosis Based on Procedure? Concussion vs Unspecified Intracranial Injury

    I'm coding a scenario in which the patient had a craniectomy due to a brain injury and the provider documented specifically that the patient had a diagnosis of "Concussion" (with loss of consciousness, 16 hrs). I'm being advised that I should be coding S06.9X4 for unspecified intracranial injury...
  5. S

    Redo right frontal craniotomy for resection of brain mass

    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...
  6. M

    Reopening Craniotomy

    I have a note for a pt. who had reopening of right frontotemporal parietal craniotomy with wound debridement & removal of mesh, cranioplasty & complex wound closure. I believe I can do 61320-supratentorial drainage of abscess, and code the complex wound closure, but I am not sure if I also need...
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