Can someone please assist me with this procedure? My doctor coded 61582 I'm not to sure if it that code.
Preoperative Diagnosis
Diagnoses This Visit
(R52)
Hyperostosis of skull (M85.2)
Mucocele of frontal sinus (J34.1)
Sinusitis chronic, frontal (J32.1)
Operation
Bicoronal craniotomy for cranialization of frontal sinus for entrapped mucocele and chronic sinusitis with ENT co-surgeon Dr. A
Sinus surgery with Dr. A as a separate procedure
The patient was identified in the holding area and brought back to operating room 9, where they were handed over to Anesthesia for a smooth induction of general anesthesia, appropriate IV access, and Foley catheter.
The patient was turned 90 degrees away from Anesthesia. Mayfield head pins were placed and secured head in position. Once this was completed, all appropriate pressure points were padded and arms were tucked. Hair sparing technique was utilized for bicoronal incision. hair was parted and held back using bacitracin ointment. The area was prepped and draped in sterile fashion using Betadine paint and scrub and allowed to dry to manufacturer's specification. Once draped and dried timeout was performed according to hospital protocol and SCIP protocol followed with clindamycin and SCDs.
Once this was done, it was infused with local anesthetic and a 10 blade was used to make an opening in the skin for a bicoronal incision that had previously been used. Bovie electrocautery was used to dissect down to the bone and the temporalis fascia. Raney clips were then applied around the edges of the cranial flap. A perforator was used to make bur holes for the planned craniotomy and then a craniotome was utilized to connect the bur holes and remove the cranial flap thought the frontal sinus on the right. Cranial flap was placed on the back table for safekeeping and was slowly elevated off the dura.
The dura was opened during the opening in this procedure due to adherent incorporation of the dura. The frontal lobes were then elevated off the frontal sinus and the sinus was immediately identified. The back wall of the sinus was then drilled away and completely removed by Dr.A as well as in the cranial flap. The brain was protected using retractors and neurosurgical intervention. Once the sinus was removed and the mucosa was removed the frontal sinus opening was then closed off with material again by Dr. A. Once the sinuses completely repaired and all the infective material was removed as well as mucocele was removed then closure started. The cranial flap was then replaced with bur hole covers and large crevice in the cranial space was covered with a cranial plating system to provide cosmetic repair. The bicoronal incision was then closed with 0 Vicryl's in the temporalis fascia followed by 2-0 Vicryl in the galea followed by 3 oh Quill Monocryl in the skin. Bacitracin ointment was placed after washing the hair.
Preoperative Diagnosis
Diagnoses This Visit
(R52)
Hyperostosis of skull (M85.2)
Mucocele of frontal sinus (J34.1)
Sinusitis chronic, frontal (J32.1)
Operation
Bicoronal craniotomy for cranialization of frontal sinus for entrapped mucocele and chronic sinusitis with ENT co-surgeon Dr. A
Sinus surgery with Dr. A as a separate procedure
The patient was identified in the holding area and brought back to operating room 9, where they were handed over to Anesthesia for a smooth induction of general anesthesia, appropriate IV access, and Foley catheter.
The patient was turned 90 degrees away from Anesthesia. Mayfield head pins were placed and secured head in position. Once this was completed, all appropriate pressure points were padded and arms were tucked. Hair sparing technique was utilized for bicoronal incision. hair was parted and held back using bacitracin ointment. The area was prepped and draped in sterile fashion using Betadine paint and scrub and allowed to dry to manufacturer's specification. Once draped and dried timeout was performed according to hospital protocol and SCIP protocol followed with clindamycin and SCDs.
Once this was done, it was infused with local anesthetic and a 10 blade was used to make an opening in the skin for a bicoronal incision that had previously been used. Bovie electrocautery was used to dissect down to the bone and the temporalis fascia. Raney clips were then applied around the edges of the cranial flap. A perforator was used to make bur holes for the planned craniotomy and then a craniotome was utilized to connect the bur holes and remove the cranial flap thought the frontal sinus on the right. Cranial flap was placed on the back table for safekeeping and was slowly elevated off the dura.
The dura was opened during the opening in this procedure due to adherent incorporation of the dura. The frontal lobes were then elevated off the frontal sinus and the sinus was immediately identified. The back wall of the sinus was then drilled away and completely removed by Dr.A as well as in the cranial flap. The brain was protected using retractors and neurosurgical intervention. Once the sinus was removed and the mucosa was removed the frontal sinus opening was then closed off with material again by Dr. A. Once the sinuses completely repaired and all the infective material was removed as well as mucocele was removed then closure started. The cranial flap was then replaced with bur hole covers and large crevice in the cranial space was covered with a cranial plating system to provide cosmetic repair. The bicoronal incision was then closed with 0 Vicryl's in the temporalis fascia followed by 2-0 Vicryl in the galea followed by 3 oh Quill Monocryl in the skin. Bacitracin ointment was placed after washing the hair.
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