amandamkcj
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Appreciate help with the following op report...looking at codes 62010 21343 but unsure that these adequately reflect/report the procedure performed.
I am coding for Dr. X so also need correct CPT with modifier i.e. 62.
Thank you in advance for your assistance!
PREOPERATIVE DIAGNOSIS:
Bifrontal depressed skull fracture
frontal sinus anterior and posterior table fracture
POSTOPERATIVE DIAGNOSIS:
Same
iatrogenic superior sagittal sinus injury
PROCEDURE:
1) Bifrontal craniotomy for elevation of depressed skull fracture
2) exhoneration of frontal sinuses
ATTENDING SURGEON: DR X
Co-ATTENDING SURGEON: Dr Y (will dictate his portion of case in separate document)
COMPLICATIONS: Iatrogenic injury to superior sagittal sinus
ANESTHESIA: General anesthesia.
ESTIMATED BLOOD LOSS: 100cc
IMPLANTS: KLS plating system, Duraform
INDICATION: The patient was struck in forehead after MVC with an open depressed frontal skull fracture with involvement of the anterior and posterior tables of the frontal sinus. We had recommended repair of this depressed fracture with exhoneration of the sinuses. Procedure and risks discussed with patient, who did express understanding and agree. However, patient was not in adequate state to obtain informed consent. D Y and I then did a 2 physician medically necessary consent.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite. The patient was positioned on the table. Patient was verified. The patient was intubated. All necessary lines were placed. The patient was positioned on the table supine in a Mayfield head holder. All pressure points were well padded. SCDs were placed. Preoperative antibiotics were started. A timeout was called.
We planned to utilize the laceration across the forehead for the repair. Patient was prepped and draped in usual sterile fashion. Proposed incision was instilled with local anesthetic.
The laceration from the trauma was extended bilaterally to the temporal areas and to expose the fractured elements. A high speed drill was used to burr in the bitemporal areas, under the temporalis muscle attachement. A Woodson and Penfield dissector was used to strip the dura off the cranium. A footplate was used to complete the craniotomy across bifrontally and across the superior sagittal sinus.
Across the sagittal sinus posteriorly, there was obvious venous injury, which was quickly controlled by using Surgiflow and bonewax. The bone flap was removed and it was found that the area of sagittal sinus injury was a portion of vein in-cased in bone. In order to gain adequate hemostasis, the superior sagittal sinus was ligated off with 2-0 silk suture, which was deemed safe as this was taking less than 1/3 of the most anterior sagittal sinus.
The posterior table of the frontal air sinus was removed with Leksell rongeours. The mucous cells were exonherated with pituitary rongeours and using sharp currette. The cavity was filled with Betadine soaked gauze.
With Dr. Y lead, the depressed nasal fracture was elevated and affixed with titanium plates and screws to the frontal bone.
On the back table, the depressed skull fracture within the bone flap was removed. Using titanium plates and screws, portion of the bone was reconstructed.
Once adequate hemostasis was achieved, the incision was copiously irrigated with antibiotic solution. We achieved meticulous hemostasis. The incision was closed in layers. First, with 2-0 vicryl sutures in interrupted fashion to close the dermis. The skin horizontally across the forehead was then closed with 4-0 monocryl suture in running fashion and covered with Dermabond. The more vertically oriented laceration skin edges were macerated and in order to close adequately, required 3-0 prolene suture in vertical mattress fashion.
At this point, Dr Y took lead and proceeded to repair the Lefort III skull fracture that will be available in a separate document.
I am coding for Dr. X so also need correct CPT with modifier i.e. 62.
Thank you in advance for your assistance!
PREOPERATIVE DIAGNOSIS:
Bifrontal depressed skull fracture
frontal sinus anterior and posterior table fracture
POSTOPERATIVE DIAGNOSIS:
Same
iatrogenic superior sagittal sinus injury
PROCEDURE:
1) Bifrontal craniotomy for elevation of depressed skull fracture
2) exhoneration of frontal sinuses
ATTENDING SURGEON: DR X
Co-ATTENDING SURGEON: Dr Y (will dictate his portion of case in separate document)
COMPLICATIONS: Iatrogenic injury to superior sagittal sinus
ANESTHESIA: General anesthesia.
ESTIMATED BLOOD LOSS: 100cc
IMPLANTS: KLS plating system, Duraform
INDICATION: The patient was struck in forehead after MVC with an open depressed frontal skull fracture with involvement of the anterior and posterior tables of the frontal sinus. We had recommended repair of this depressed fracture with exhoneration of the sinuses. Procedure and risks discussed with patient, who did express understanding and agree. However, patient was not in adequate state to obtain informed consent. D Y and I then did a 2 physician medically necessary consent.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite. The patient was positioned on the table. Patient was verified. The patient was intubated. All necessary lines were placed. The patient was positioned on the table supine in a Mayfield head holder. All pressure points were well padded. SCDs were placed. Preoperative antibiotics were started. A timeout was called.
We planned to utilize the laceration across the forehead for the repair. Patient was prepped and draped in usual sterile fashion. Proposed incision was instilled with local anesthetic.
The laceration from the trauma was extended bilaterally to the temporal areas and to expose the fractured elements. A high speed drill was used to burr in the bitemporal areas, under the temporalis muscle attachement. A Woodson and Penfield dissector was used to strip the dura off the cranium. A footplate was used to complete the craniotomy across bifrontally and across the superior sagittal sinus.
Across the sagittal sinus posteriorly, there was obvious venous injury, which was quickly controlled by using Surgiflow and bonewax. The bone flap was removed and it was found that the area of sagittal sinus injury was a portion of vein in-cased in bone. In order to gain adequate hemostasis, the superior sagittal sinus was ligated off with 2-0 silk suture, which was deemed safe as this was taking less than 1/3 of the most anterior sagittal sinus.
The posterior table of the frontal air sinus was removed with Leksell rongeours. The mucous cells were exonherated with pituitary rongeours and using sharp currette. The cavity was filled with Betadine soaked gauze.
With Dr. Y lead, the depressed nasal fracture was elevated and affixed with titanium plates and screws to the frontal bone.
On the back table, the depressed skull fracture within the bone flap was removed. Using titanium plates and screws, portion of the bone was reconstructed.
Once adequate hemostasis was achieved, the incision was copiously irrigated with antibiotic solution. We achieved meticulous hemostasis. The incision was closed in layers. First, with 2-0 vicryl sutures in interrupted fashion to close the dermis. The skin horizontally across the forehead was then closed with 4-0 monocryl suture in running fashion and covered with Dermabond. The more vertically oriented laceration skin edges were macerated and in order to close adequately, required 3-0 prolene suture in vertical mattress fashion.
At this point, Dr Y took lead and proceeded to repair the Lefort III skull fracture that will be available in a separate document.