nauger
Networker
Looking for help on coding the below dictation for a crainectomy.
A single bur hole was drilled in the frontal region and a craniotomy flap was fashioned after confirmation of the tumor location using stereotactic guidance. Again, once the brain was identified, the skull appeared to be significantly hyperostatic and some of the hyperostotic bone was sent for pathology. The brain itself seemed to be somewhat edematous. The frontal lobe was cauterized. Biopsies were taken both from the brain tissue and from what appeared to be a clear to straw-colored fluid and both he cyst and the cyst wall were taken and sent for cultures as well as cytology and pathology. By the end of the resection, the cyst appeared to be completely drained and the bran appeared to be more relaxed. The cyst wall was lined with surgical as well as gelfoam for hemostasis. The craniotomy flap was reattached using plates and screws.
We were looking at codes: '61510' "61516' '61781'
The physicians stated that there was both a tumor and a cyst, but the dictation does not clearly state if he removed one or both.
Thank you for your help!
A single bur hole was drilled in the frontal region and a craniotomy flap was fashioned after confirmation of the tumor location using stereotactic guidance. Again, once the brain was identified, the skull appeared to be significantly hyperostatic and some of the hyperostotic bone was sent for pathology. The brain itself seemed to be somewhat edematous. The frontal lobe was cauterized. Biopsies were taken both from the brain tissue and from what appeared to be a clear to straw-colored fluid and both he cyst and the cyst wall were taken and sent for cultures as well as cytology and pathology. By the end of the resection, the cyst appeared to be completely drained and the bran appeared to be more relaxed. The cyst wall was lined with surgical as well as gelfoam for hemostasis. The craniotomy flap was reattached using plates and screws.
We were looking at codes: '61510' "61516' '61781'
The physicians stated that there was both a tumor and a cyst, but the dictation does not clearly state if he removed one or both.
Thank you for your help!