Wiki Cranioplasty with Tissue Rearrangment

alammert

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Can someone please take a look at the procedure below and advise? This is a rare procedure for me to code and want another opinion if you could be so kind, I truly appreciate any input. : )
I'm looking at 62141-Cranioplasty & 14021-tissue rearrangement with 62 modifier.

OPERATIONS PERFORMED:
1. Coronal exposure of 9 x 11 cm metastatic breast cancer mass of the scalp
2. Cranioplasty covering an area of 10 x 11 cm using a titanium mesh.
3. Layered closure of 27 cm coronal incision.

ANESTHESIA: General.

INDICATIONS: A 59-year-old female who has had 2 lumpectomies for breast cancer. She now presents to the clinic with a large metastatic tumor to her skull. She is referred to me from Dr. Y for exposure of the defect, performance of the cranioplasty, and wound closure and tissue rearrangement if needed.

DESCRIPTION OF OPERATION: Patient was properly identified in the holding area. Consent was obtained after explaining the risks and benefits of the procedure which include but are not limited to bleeding, infection, damage to surrounding structures, need for the surgery, wound breakdown, need for a local or free flap versus scalp rearrangement, death, scalp asymmetry. She agreed to proceed. She was then taken to the operating room and she was laid in the supine position. Adequate anesthesia was obtained. All of her lines were placed. She was then adequately padded. Her head was then mobilized on the neurosurgical Mayfield. Her scalp was then trimmed along the path of the coronal incision. The marks were then made with care taken to include her superficial temporal vessels in the posterior flap that involves the tumor. It was then injected with local 1:100,000 epinephrine. She was then prepped and draped in a sterile fashion. Attention was then turned towards exposure. A 10- blade was used to make the incision down through the subcutaneous tissue and through the galea. The incision was carried from ear to ear. The dissection was in the subgaleal plane. The total area of undermining was 27 cm x 20 cm. The scalp was then reflected posteriorly. The mass was then completely exposed. Cuts were made through the pericranium to expose the skull and tumor. Dr. Y then performed his portion of the procedure for resection of the cranial mass--Please see his dictation for full details. I then reentered once the mass was removed. I then cut a titanium mesh that measured 11 x 10.5 cm. I then held it into place and we secured it with multiple screws around the periphery to ensure good contour against her skull. The area was then copiously irrigated. Hemostasis was once again obtained with electrocautery. Two drains were then placed, 1 behind each ear. They were sutured in place with 3-0 nylon sutures. A 2-0 Vicryl was then used in interrupted fashion to reapproximate the galea. Staples were then used for final closure after reapproximation of the scalp. Bacitracin and Xeroform were applied followed by a sterile compressive head wrap.
 
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