Wiki bundling b/w 62164 and 62201

ijackson

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Assistance is needed…

Does anyone know what the reason “CPT Manual or CMS Manual Coding Instructions” mean? Not sure if I should add modifier 51 or 59. I’m thinking 51 since it was at the same location but I’m not sure. Neither codes says it includes the other code, in fact, code 62201 states:

Excludes Intracranial neuroendoscopic surgery (62161-62165)

Let me know your thoughts.


OpNote:

PREOPERATIVE DIAGNOSIS: Pineal region tumor with hydrocephalus.

POSTOPERATIVE DIAGNOSIS: Pineal region tumor with hydrocephalus.

PROCEDURES PERFORMED:
1. Endoscopic 3rd ventriculostomy.
2. Biopsy/partial resection of pineal region tumor.

INDICATION FOR PROCEDURE: This is a 29-year-old man, who has
baseline intellectual deficiency. He began to have headaches,
nausea, vomiting, and difficulty with ambulation around Christmas
Eve. This progressed to where he was unable to stand, and then he
presented to the Emergency Department at an outside hospital where
he underwent MRI of his spine. This revealed hydrocephalus and
pineal region mass, and he was transferred to Community Hospital
North for definitive management, underwent MRI of the brain, which
revealed a large heterogeneously enhancing 30 mm mass above the
midbrain tectum with mass effect on the aqueduct with resultant
obstructive hydrocephalus. The patient had an EVD placed emergently
as he was becoming obtunded at the time of initial evaluation and
then CSF tumor markers were sent, which were inconclusive; therefore
for both treatment of his hydrocephalus and diagnosis with tissue
sampling, the patient was amenable to endoscopic 3rd ventriculostomy
and biopsy. Informed consent was obtained from his mother.

DESCRIPTION OF PROCEDURE: The patient was brought into the
operating room, placed under general endotracheal anesthesia by the
Anesthesia service. He was then placed supine on the operating
table, head in Mayfield three-point pin fixation. Stealth
stereotactic navigation system was set to the patient's MRI and CT
scan used for navigation throughout the duration of the procedure.
The previous EVD site was identified. All staples were removed, and
the ventriculostomy catheter was removed. The right frontal area
was then prepped and draped in usual sterile fashion. Preop
time-out was performed. Cefazolin was given for antibiotic.

The incision was opened with a #10 blade, and a self-retaining
retractor was established after subperiosteal technique used to
elevate the scalp flap. High-speed drill was used to expand the
burr hole from the EVD placement, and the hemostasis was obtained in
the epidural space with Gelfoam thrombin powder, bipolar
electrocautery, and bone wax. Dura was opened in a cruciate fashion
and then using Mitaka arm as an endoscope holder, an obturator with
stealth stereotactic navigation was advanced in the ventricle. The
endoscope was then advanced into this, and landmarks were confirmed
including the septal vein, thalamostriate vein, choroid plexus, and
the head of the fornix. We then continued advancing the endoscope
into the 3rd ventricle, identifying the mass intermedia, and the
mammillary bodies as well as the suprachiasmatic and
infundibular recesses, just anterior the mamillary bodies was
visualized, a thin membrane of tissue, which was the tuber cinereum.
A 3-French Fogarty catheter was carefully advanced into this, and
the balloon was inflated. This created the ventriculostomy and expanded
the opening.
The basilar artery was visualized through this and the
interpeduncular cistern. We then turned attention posteriorly where
the tumor was visualized as an erythematous mass, extending into the
pineal lesion. This was inspected and 30 degree endoscope was
inserted, and we were able to sample the tumor with grasping
forceps.
There was some bleeding from the tumor during this
process, which was controlled with continuous lactated Ringer's
irrigation through the endoscope as well as with occasional
tamponade. Using the endoscope, all blood clots were evacuated using
grasping forceps and the bloody debris was irrigated out using the
endoscopes irrigation. Once adequate tissue specimen had been
harvested, these were sent for frozen specimen, which was confirmed
to be lesional tissue. We then harvested more tumor for permanent
specimen, completing the biopsy portion of the procedure, and the
endoscope was then withdrawn from the 3rd ventricle. The 3rd
ventriculostomy was again inspected for patency, and was found to be
satisfactory.
We then backed out the entire endoscope and sheath,
and visualized the tract which had good hemostasis. A Helistat
pledget was placed in the epidural space. Another EVD drain was
placed into this tract down into the ventricle, and tunneled out of
the skin and secured with staples. A Synthes cranial fixation bur
hole plate cover was placed on the bur hole and secured in position
with screws. Copious bacitracin irrigation was used to wash out the
field. Incision was closed in layers with interrupted inverted 2-0
Vicryl in the galea followed by staples in the skin. The wound was
cleansed and dried, dressed with Telfa and Tegaderm. Patient was
escorted back to anesthesia for extubation, taken back in stable
condition with no complications. Specimens were as above. Closing
time-out was performed. Sponge and needle counts were correct x2 at
the end of the case.
 
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