Coding

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12
Location
Greater Philadelphia
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0
Please assist with cpt coding. Not that proficient when comes to coding this procedure. Thank you.

ESTIMATED BLOOD LOSS:  200.

REPLACEMENTS:  1 unit of packed cells, 1 unit of FFP.

PREOPERATIVE DIAGNOSIS:  Posterior fossa arteriovenous malformation.

POSTOPERATIVE DIAGNOSIS:  Posterior fossa arteriovenous malformation.

PROCEDURE:  Suboccipital craniectomy with left-sided dural opening with hematoma evacuation and a C1 laminectomy with dural opening down to the top of C2.

INDICATIONS:  The patient is a 10-year-old girl who yesterday collapsed and was felt to have an AVM that was confirmed on CTA and angiogram.  She had an angiogram with embolization.  However, they were unable to embolize completely the AVM.  After the ventriculostomy and overnight she was more stable and following embolization she was taken directly from the angio suite to the OR for decompressive posterior fossa craniectomy and durotomy.

DESCRIPTION OF PROCEDURE:  Once in the operating room, she was placed in the Mayfield head holder and flipped into the prone position.  She has been intubated since arrival.  She was then sterilely prepped and draped in usual fashion.  Time-out was taken prior to skin incision.  A 15 blade knife was used to make a linear incision in her scalp from above the inion down to C2.  Soft tissue was dissected off the bone.  Three bur holes were placed and a craniotome used to turn a craniotomy.  We then did a C1 laminectomy and with rongeurs and Kerrison punches widened the posterior fossa craniectomy.  Because of the very large draining vein just under the dura and likely increased pressure, the decision was made not to open the dura in the midline for fear that as the brain swelled that one of the AVM veins would tear and we would not be able to control the bleeding.  Therefore, we opened over the left cerebellar hemisphere in a cruciate fashion.  The cerebellum rapidly came herniating out.  There was also some subdural blood as well as parenchymal hematoma that we evacuated.  We then continued down to the foramen magnum and opened down to C2.  We could see very large dilated veins that were arterialized over the upper spinal cord and lower brainstem.  We did not experience any bleeding from the AVM.  The blood pressure improved after the durotomy.  Meticulous hemostasis was achieved.  The decision was made not to open the right side and rather to just close.  The incision was closed in layers with resorbable suture.  A drain was left behind in the subfascial area and the skin edge reapproximated with staples.  The patient was taken to the PICU in critical condition.  I was present for and participated in the critical portions of the case.
 
Messages
12
Location
Greater Philadelphia
Best answers
0
Please assist with cpt coding. Not that proficient when comes to coding this procedure. Thank you.

ESTIMATED BLOOD LOSS:  200.

REPLACEMENTS:  1 unit of packed cells, 1 unit of FFP.

PREOPERATIVE DIAGNOSIS:  Posterior fossa arteriovenous malformation.

POSTOPERATIVE DIAGNOSIS:  Posterior fossa arteriovenous malformation.

PROCEDURE:  Suboccipital craniectomy with left-sided dural opening with hematoma evacuation and a C1 laminectomy with dural opening down to the top of C2.

INDICATIONS:  The patient is a 10-year-old girl who yesterday collapsed and was felt to have an AVM that was confirmed on CTA and angiogram.  She had an angiogram with embolization.  However, they were unable to embolize completely the AVM.  After the ventriculostomy and overnight she was more stable and following embolization she was taken directly from the angio suite to the OR for decompressive posterior fossa craniectomy and durotomy.

DESCRIPTION OF PROCEDURE:  Once in the operating room, she was placed in the Mayfield head holder and flipped into the prone position.  She has been intubated since arrival.  She was then sterilely prepped and draped in usual fashion.  Time-out was taken prior to skin incision.  A 15 blade knife was used to make a linear incision in her scalp from above the inion down to C2.  Soft tissue was dissected off the bone.  Three bur holes were placed and a craniotome used to turn a craniotomy.  We then did a C1 laminectomy and with rongeurs and Kerrison punches widened the posterior fossa craniectomy.  Because of the very large draining vein just under the dura and likely increased pressure, the decision was made not to open the dura in the midline for fear that as the brain swelled that one of the AVM veins would tear and we would not be able to control the bleeding.  Therefore, we opened over the left cerebellar hemisphere in a cruciate fashion.  The cerebellum rapidly came herniating out.  There was also some subdural blood as well as parenchymal hematoma that we evacuated.  We then continued down to the foramen magnum and opened down to C2.  We could see very large dilated veins that were arterialized over the upper spinal cord and lower brainstem.  We did not experience any bleeding from the AVM.  The blood pressure improved after the durotomy.  Meticulous hemostasis was achieved.  The decision was made not to open the right side and rather to just close.  The incision was closed in layers with resorbable suture.  A drain was left behind in the subfascial area and the skin edge reapproximated with staples.  The patient was taken to the PICU in critical condition.  I was present for and participated in the critical portions of the case.
 
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