sdunaway1
Guru
I believe the cpt code should be 61516,61781,69990 but my neurosurgeon states that this was a very difficult surgery and the RVU is too low for the risk involved. Can you please check the documentation and see if you agree? I am considering adding a modifier 22 . Thank you for your help !
PREOPERATIVE DIAGNOSIS: Colloid cyst of the third ventricle measuring 8 x 6.5 mm in size.
POSTOPERATIVE DIAGNOSIS: Colloid cyst of the third ventricle measuring 8 x 6.5 mm in size.
OPERATION PERFORMED: Right frontal Stealth stereotactic craniotomy with an interhemispheric
transcallosal approach to remove this colloid cyst of the third ventricle.
SURGEON:
FIRST ASSISTANT:
ANESTHESIA: General.
PREOPERATIVE MEDICATION: Cefazolin 2 grams IV in induction, repeated 3 hours into the case.
Also mannitol 100 gm given IV on induction.
PREOPERATIVE SUMMARY: The patient is a 29-year-old white male with a history of a motor
vehicle crash earlier this year. Head CT scan was obtained, which showed a hyperdense area
in the area of the roof of the third ventricle and the differential diagnosis was either
posttraumatic trauma versus colloid cyst. I was asked to review the CT scan. I felt it was
most likely a colloid cyst. We recommend awaiting 6 weeks to 2 months with a rescan and if
the hyperdensity went away, then we would elevate with blood, but if not we would know it
was a colloid cyst. He came back approximately 2 months later where repeat head CT scan was
obtained and showed the same hyperdensity measuring approximately 8.4 mm in size. It was
right above the foramina of Monro in the anterior portion of the third ventricle. I ordered
an MRI scan of the brain with and without IV contrast, which showed a nonenhancing mass
bright on T1 weighted images and on T2 weighted images consistent with colloid cyst of the
third ventricle. Based on this finding, I did have a number discussions with him about
treatment options. One would be to just simply wait and repeat MRI scans periodically and as
it enlarged and started to cause hydrocephalus, then consider surgical removal at that time
or to consider surgery to prevent hydrocephalus from occurring in the first place. I
discussed 2 treatment options, one through an endoscopic approach. I did discuss it with
Dr. Ben Ling in Spokane who does these endoscopic procedures. He said it was extremely hard
to be able to remove it with endoscopic approach, especially with small ventricles. Based
on this, if he decided to proceed with surgery, I did recommend a right interhemispheric
approach to remove this mass. After a long discussion about treatment options he eventually
decided to proceed with surgery to remove the colloid cyst to prevent potentially acute
hydrocephalus in the future. I did discuss the surgical procedure with him. I did explain
the potential benefits and risks of surgery including potential risks of CSF leak,
postoperative wound hematoma, possibility of increased weakness and sensation loss either
upper and/or lower extremities after surgery, the possibility of intraventricular blood
requiring placement of ventriculostomy after surgery, the possibility of incomplete removal
of the colloid cyst, the possibility of stroke typically anterior cerebral artery
distribution since the procedure is done right between the 2 pericallosal arteries, the
possibility of postoperative mutism which can occur 5%-10% of the time is usually temporary,
and the biggest risk is short-term memory loss from working between the 2 fornices. I did
discuss the surgical procedure with the patient at length and ultimately decided to proceed
with surgery. The patient fully understood the potential benefits and risks of surgery and
Name: Status: ADM IN OPERATIVE REPORT
Acct #: KM0021798894 Rm/Bed: 2204-01
MR #: KM00083778 Provider:
KOOTENAI HEALTH
Coeur d'Alene, ID 83814
consented to the surgical procedure described above.
OPERATIVE SUMMARY: The patient was brought to the preoperative area. His head was shaved.
Fiducial markers were placed on his scalp. He went down for a Stealth stereotactic T1
weighted MRI scan with contrast and the first one actually showed too much movement so he
had to go back down, repeat it, this time we had an adequate study. Following this, the
data from the MRI scan was loaded into the Stealth stereotactic computer in the operating
room and each of the fiducial markers was entered and a surgical plan was developed by me.
Following this, the patient was brought into the operating room, laid on the operative table
in the supine position where he underwent successful induction of general anesthesia and
placement of an endotracheal tube. Correct placement of the ET tube was checked by
Anesthesia. When it was confirmed to be in the correct position, the airway was secured.
The patient was placed in a supine position with the neck flexed up approximately 30-40
degrees from supine and then placed in Mayfield head fixation. At this time, each of the
fiducial markers was then reregistered into the computer with an error of less than 1 mm
accomplished. Following this, in its coronal, a bicoronal incision was planned beginning
just in front of the patient's right tragus brought over and down to just above the
patient's left tragus. The head of the patient was shaved, prepped and draped off in a
sterile manner using a double glove technique.
At this time, a timeout was taken in the operating room where the case to be performed was
discussed including potential complications. We checked to make sure we had all the
equipment ready and available to perform the surgery. We did the usual preoperative
checklist.
At this time, an incision was carried out as described above. Raney clips were applied to
the edges of the skin and then the scalp was reflected anteriorly over the patient's
forehead and the scalp was able to be folded over and then this was covered with an
antibiotic-soaked sponge. The midline was identified with stereotaxis and marked on the
patient's skull and I placed 3 bur holes, 2 over the mid sagittal sinus, 1 approximately 5
mm anterior to the coronal suture and then the second one placed approximately 2.5-3 cm
posterior to the coronal suture in the midline and another 1 off to the right side
approximately 5 cm laterally. Bur holes were placed. Once they were placed the dura was
reflected away from the inner concavity of the skull between the bur holes and then using
the Midas Rex dissecting tool, cuts were made between the bur holes. The bone flap was
removed and placed on the back table. This fully exposed the midsagittal sinus between the
front and the back bur holes. Hemostasis was accomplished in the dura. Dural tenting
sutures were placed around the perimeter to decrease epidural bleeding.
Using a 15 blade, the dura was then opened and then using Metzenbaum scissors the dura was
opened extending from anteriorly just lateral to the midsagittal sinus and then brought
laterally and then eventually again posteriorly again just to the posterior lateral right
edge of the midsagittal sinus. There were several bridging veins which were identified,
they were cauterized and divided as well as pacchionian granulations which were cauterized
and divided also. The dura was then reflected laterally with a saline-soaked cottonoid over
this. At this point, after the dura was opened the brain was found to be pulsatile and
relaxed. At this point, a very careful dissection was carried down along the medial border
of the patient's frontal lobe and the falx. There were a number of adhesions which were
cauterized and divided and CSF was allowed to drain, which allowed better relaxation and
less retraction on the right medial frontal lobe.
At this time, the operating microscope was brought into the field. The remainder of the
procedure was done under microscopic illumination and magnification using microdissection
technique. Under the operating microscope, the interhemispheric space between the 2
cingulate gyri were then carefully dissected out using microdissection technique and then
identifying both the pericallosal as well as the callosal marginal arteries, which were
divided. This exposed the corpus callosum, which was a fairly bright white color.
Retractor blades were placed on both sides, minimizing the amount of retraction necessary to
access the corpus callosum in the midline. Self-retaining Greenberg retractors were used to
hold the exposure. I should mention the retractors were removed periodically during the
case to decrease the length of retraction of the right medial temporal lobe in particular
throughout the case. Under the operating microscope, the corpus callosum was divided and
carried down to the septum pellucidum and I entered both the right and the left ventricles,
both were quite small. The right side was slightly larger than the left. I did open up the
septum pellucidum and removed it to come down to the space between the 2 fornices,
identified both foramina of Monro as well as the septal vein and the thalamostriate vein
bilaterally to help locate the foramen of Monro. There was clearly a mass between the
fornices more posterior to the foramen of Monro and actually looking through the foramina of
Monro the colloid cyst could not be identified, it was more posterior. At this point, I
felt I had to go between the 2 fornices and so using an 11 blade I did divide down the
midline between the 2 fornices and then working with bipolar cautery and microdissection
technique worked down the midline until the colloid cyst was identified. I dissected around
it as much as I was able to, but unable to remove in 1 piece. Using a 15 blade under the
operating microscope, I did open into the colloid cyst and gradually and incrementally
removed the particles of it and eventually the entire cyst wall, part of which was sent for
permanent section both gross and microscopic pathological diagnosis. The third ventricle
was clearly exposed. I was able to inspect it and there was no evidence of any bleeding or
any fragments of the colloid cyst blocking the cerebral aqueduct or either the foramina of
Monro which were widely patent. At this time, I carried out very careful hemostasis
throughout the field gradually starting from the third ventricle working upward layer by
layer to obtain good hemostasis throughout the field. Eventually, the retractors were
removed. I did place Surgicel along the exposed right medial frontal lobe as well as the
left cingulate gyrus and then the interhemispheric space closed up as the brain reexpanded
after the retractors were removed. Following this, the cortical surface was then irrigated.
There was some subdural blood which had accumulated during surgery and this was irrigated
out. Once hemostasis was accomplished, I did carry out a Valsalva maneuver with no active
bleeding seen. At this time, the dura was then closed in layers in usual fashion. Before
the final dural sutures were placed I did bring the patient almost up into a sitting
position before I placed the last sutures in and of course I irrigated with sterile warm
normal saline to irrigate out as much air from the cranium as possible. Following this, I
placed DuraGen over the suture line and over this a piece of Gelfoam and then the bone flap
was reattached. A dural tenting suture was placed and brought up through the center of the
bone flap and tied to decrease the chance of accumulating epidural blood or fluid. The bone
flap was reattached to the surrounding cranium using the Synthes craniofacial plating
system to obtain rigid fixation of the bone flap to the surrounding cranium. Following
this, the entire field was then irrigated with bacitracin normal saline solution.
Hemostasis was accomplished and then the scalp was closed in layers in the usual fashion
with the skin being closed with skin staples. This was then dressed with bacitracin
ointment, Telfa, sterile 4 x 4's were taped to the patient's scalp. I then wrapped his head
in 2 Kerlix bandages and a Kling. The patient then underwent successful reversal of general
anesthesia and extubation in the operating room. He was moving both upper and lower
extremities at the end the procedure and left the operating room in stable condition.
PREOPERATIVE DIAGNOSIS: Colloid cyst of the third ventricle measuring 8 x 6.5 mm in size.
POSTOPERATIVE DIAGNOSIS: Colloid cyst of the third ventricle measuring 8 x 6.5 mm in size.
OPERATION PERFORMED: Right frontal Stealth stereotactic craniotomy with an interhemispheric
transcallosal approach to remove this colloid cyst of the third ventricle.
SURGEON:
FIRST ASSISTANT:
ANESTHESIA: General.
PREOPERATIVE MEDICATION: Cefazolin 2 grams IV in induction, repeated 3 hours into the case.
Also mannitol 100 gm given IV on induction.
PREOPERATIVE SUMMARY: The patient is a 29-year-old white male with a history of a motor
vehicle crash earlier this year. Head CT scan was obtained, which showed a hyperdense area
in the area of the roof of the third ventricle and the differential diagnosis was either
posttraumatic trauma versus colloid cyst. I was asked to review the CT scan. I felt it was
most likely a colloid cyst. We recommend awaiting 6 weeks to 2 months with a rescan and if
the hyperdensity went away, then we would elevate with blood, but if not we would know it
was a colloid cyst. He came back approximately 2 months later where repeat head CT scan was
obtained and showed the same hyperdensity measuring approximately 8.4 mm in size. It was
right above the foramina of Monro in the anterior portion of the third ventricle. I ordered
an MRI scan of the brain with and without IV contrast, which showed a nonenhancing mass
bright on T1 weighted images and on T2 weighted images consistent with colloid cyst of the
third ventricle. Based on this finding, I did have a number discussions with him about
treatment options. One would be to just simply wait and repeat MRI scans periodically and as
it enlarged and started to cause hydrocephalus, then consider surgical removal at that time
or to consider surgery to prevent hydrocephalus from occurring in the first place. I
discussed 2 treatment options, one through an endoscopic approach. I did discuss it with
Dr. Ben Ling in Spokane who does these endoscopic procedures. He said it was extremely hard
to be able to remove it with endoscopic approach, especially with small ventricles. Based
on this, if he decided to proceed with surgery, I did recommend a right interhemispheric
approach to remove this mass. After a long discussion about treatment options he eventually
decided to proceed with surgery to remove the colloid cyst to prevent potentially acute
hydrocephalus in the future. I did discuss the surgical procedure with him. I did explain
the potential benefits and risks of surgery including potential risks of CSF leak,
postoperative wound hematoma, possibility of increased weakness and sensation loss either
upper and/or lower extremities after surgery, the possibility of intraventricular blood
requiring placement of ventriculostomy after surgery, the possibility of incomplete removal
of the colloid cyst, the possibility of stroke typically anterior cerebral artery
distribution since the procedure is done right between the 2 pericallosal arteries, the
possibility of postoperative mutism which can occur 5%-10% of the time is usually temporary,
and the biggest risk is short-term memory loss from working between the 2 fornices. I did
discuss the surgical procedure with the patient at length and ultimately decided to proceed
with surgery. The patient fully understood the potential benefits and risks of surgery and
Name: Status: ADM IN OPERATIVE REPORT
Acct #: KM0021798894 Rm/Bed: 2204-01
MR #: KM00083778 Provider:
KOOTENAI HEALTH
Coeur d'Alene, ID 83814
consented to the surgical procedure described above.
OPERATIVE SUMMARY: The patient was brought to the preoperative area. His head was shaved.
Fiducial markers were placed on his scalp. He went down for a Stealth stereotactic T1
weighted MRI scan with contrast and the first one actually showed too much movement so he
had to go back down, repeat it, this time we had an adequate study. Following this, the
data from the MRI scan was loaded into the Stealth stereotactic computer in the operating
room and each of the fiducial markers was entered and a surgical plan was developed by me.
Following this, the patient was brought into the operating room, laid on the operative table
in the supine position where he underwent successful induction of general anesthesia and
placement of an endotracheal tube. Correct placement of the ET tube was checked by
Anesthesia. When it was confirmed to be in the correct position, the airway was secured.
The patient was placed in a supine position with the neck flexed up approximately 30-40
degrees from supine and then placed in Mayfield head fixation. At this time, each of the
fiducial markers was then reregistered into the computer with an error of less than 1 mm
accomplished. Following this, in its coronal, a bicoronal incision was planned beginning
just in front of the patient's right tragus brought over and down to just above the
patient's left tragus. The head of the patient was shaved, prepped and draped off in a
sterile manner using a double glove technique.
At this time, a timeout was taken in the operating room where the case to be performed was
discussed including potential complications. We checked to make sure we had all the
equipment ready and available to perform the surgery. We did the usual preoperative
checklist.
At this time, an incision was carried out as described above. Raney clips were applied to
the edges of the skin and then the scalp was reflected anteriorly over the patient's
forehead and the scalp was able to be folded over and then this was covered with an
antibiotic-soaked sponge. The midline was identified with stereotaxis and marked on the
patient's skull and I placed 3 bur holes, 2 over the mid sagittal sinus, 1 approximately 5
mm anterior to the coronal suture and then the second one placed approximately 2.5-3 cm
posterior to the coronal suture in the midline and another 1 off to the right side
approximately 5 cm laterally. Bur holes were placed. Once they were placed the dura was
reflected away from the inner concavity of the skull between the bur holes and then using
the Midas Rex dissecting tool, cuts were made between the bur holes. The bone flap was
removed and placed on the back table. This fully exposed the midsagittal sinus between the
front and the back bur holes. Hemostasis was accomplished in the dura. Dural tenting
sutures were placed around the perimeter to decrease epidural bleeding.
Using a 15 blade, the dura was then opened and then using Metzenbaum scissors the dura was
opened extending from anteriorly just lateral to the midsagittal sinus and then brought
laterally and then eventually again posteriorly again just to the posterior lateral right
edge of the midsagittal sinus. There were several bridging veins which were identified,
they were cauterized and divided as well as pacchionian granulations which were cauterized
and divided also. The dura was then reflected laterally with a saline-soaked cottonoid over
this. At this point, after the dura was opened the brain was found to be pulsatile and
relaxed. At this point, a very careful dissection was carried down along the medial border
of the patient's frontal lobe and the falx. There were a number of adhesions which were
cauterized and divided and CSF was allowed to drain, which allowed better relaxation and
less retraction on the right medial frontal lobe.
At this time, the operating microscope was brought into the field. The remainder of the
procedure was done under microscopic illumination and magnification using microdissection
technique. Under the operating microscope, the interhemispheric space between the 2
cingulate gyri were then carefully dissected out using microdissection technique and then
identifying both the pericallosal as well as the callosal marginal arteries, which were
divided. This exposed the corpus callosum, which was a fairly bright white color.
Retractor blades were placed on both sides, minimizing the amount of retraction necessary to
access the corpus callosum in the midline. Self-retaining Greenberg retractors were used to
hold the exposure. I should mention the retractors were removed periodically during the
case to decrease the length of retraction of the right medial temporal lobe in particular
throughout the case. Under the operating microscope, the corpus callosum was divided and
carried down to the septum pellucidum and I entered both the right and the left ventricles,
both were quite small. The right side was slightly larger than the left. I did open up the
septum pellucidum and removed it to come down to the space between the 2 fornices,
identified both foramina of Monro as well as the septal vein and the thalamostriate vein
bilaterally to help locate the foramen of Monro. There was clearly a mass between the
fornices more posterior to the foramen of Monro and actually looking through the foramina of
Monro the colloid cyst could not be identified, it was more posterior. At this point, I
felt I had to go between the 2 fornices and so using an 11 blade I did divide down the
midline between the 2 fornices and then working with bipolar cautery and microdissection
technique worked down the midline until the colloid cyst was identified. I dissected around
it as much as I was able to, but unable to remove in 1 piece. Using a 15 blade under the
operating microscope, I did open into the colloid cyst and gradually and incrementally
removed the particles of it and eventually the entire cyst wall, part of which was sent for
permanent section both gross and microscopic pathological diagnosis. The third ventricle
was clearly exposed. I was able to inspect it and there was no evidence of any bleeding or
any fragments of the colloid cyst blocking the cerebral aqueduct or either the foramina of
Monro which were widely patent. At this time, I carried out very careful hemostasis
throughout the field gradually starting from the third ventricle working upward layer by
layer to obtain good hemostasis throughout the field. Eventually, the retractors were
removed. I did place Surgicel along the exposed right medial frontal lobe as well as the
left cingulate gyrus and then the interhemispheric space closed up as the brain reexpanded
after the retractors were removed. Following this, the cortical surface was then irrigated.
There was some subdural blood which had accumulated during surgery and this was irrigated
out. Once hemostasis was accomplished, I did carry out a Valsalva maneuver with no active
bleeding seen. At this time, the dura was then closed in layers in usual fashion. Before
the final dural sutures were placed I did bring the patient almost up into a sitting
position before I placed the last sutures in and of course I irrigated with sterile warm
normal saline to irrigate out as much air from the cranium as possible. Following this, I
placed DuraGen over the suture line and over this a piece of Gelfoam and then the bone flap
was reattached. A dural tenting suture was placed and brought up through the center of the
bone flap and tied to decrease the chance of accumulating epidural blood or fluid. The bone
flap was reattached to the surrounding cranium using the Synthes craniofacial plating
system to obtain rigid fixation of the bone flap to the surrounding cranium. Following
this, the entire field was then irrigated with bacitracin normal saline solution.
Hemostasis was accomplished and then the scalp was closed in layers in the usual fashion
with the skin being closed with skin staples. This was then dressed with bacitracin
ointment, Telfa, sterile 4 x 4's were taped to the patient's scalp. I then wrapped his head
in 2 Kerlix bandages and a Kling. The patient then underwent successful reversal of general
anesthesia and extubation in the operating room. He was moving both upper and lower
extremities at the end the procedure and left the operating room in stable condition.