I need help please with coding this OP Report. I was looking at 2 different sets of CPT's. 1st set: 61583, 61601 2nd set: 61512, 31085. I'm just not sure which one would be correct.
PREOPERATIVE DIAGNOSIS: Left frontal tumor.
POSTOPERATIVE DIAGNOSIS: Apoplectic left falcine meningioma.
PROCEDURES PERFORMED:
1. Bicoronal skin incision with bifrontal craniotomy for excision of falcine meningioma.
2. Cranialization exoneration of the frontal sinus and repair with a vascularized pericranial flap.
2. Microsurgery.
3. Intraoperative image guidance using the Stealth.
DESCRIPTION OF PROCEDURE: The patient was identified. After the establishment of general endotracheal tube anesthesia, the patient's head was secured in Mayfield pinion headrest and it was registered in the Stealth for the purpose of intraoperative image guidance. After sterile preparation and drape, a time-out was performed. A bicoronal skin incision was made and then a bifrontal bone flap was made eccentric to the left. The patient had a high and large frontal sinus and it was necessary to enter the frontal sinus during the course of exposure. The frontal sinus was then stripped of mucosa and the ostea of the frontal sinus were fused with bone dust. The cranial posterior wall of the frontal sinus was removed thereby cranializing the sinus. The sinus was obliterated with biologic glue and Gelfoam. It was then covered with a vascularized pericranial flap that was harvested from the scalp flap. The dura was opened in a circumferential manner around the tumor. Tumor itself was extraaxial and appeared to be arising from the falx at the junction of the falx and skull base. The border of the tumor was developed and the falx sectioned after the superior sagittal sinus had been ligated in that area. The tumor and its dural origin were removed as a single piece. Immaculate hemostasis was achieved. The dura was repaired with a dural graft. The bone plate was securely plated in place and the remainder of the wound was dried and closed in layers over a Jackson-Pratt drain and a dry sterile dressing applied.
Thank you,
Joanne
PREOPERATIVE DIAGNOSIS: Left frontal tumor.
POSTOPERATIVE DIAGNOSIS: Apoplectic left falcine meningioma.
PROCEDURES PERFORMED:
1. Bicoronal skin incision with bifrontal craniotomy for excision of falcine meningioma.
2. Cranialization exoneration of the frontal sinus and repair with a vascularized pericranial flap.
2. Microsurgery.
3. Intraoperative image guidance using the Stealth.
DESCRIPTION OF PROCEDURE: The patient was identified. After the establishment of general endotracheal tube anesthesia, the patient's head was secured in Mayfield pinion headrest and it was registered in the Stealth for the purpose of intraoperative image guidance. After sterile preparation and drape, a time-out was performed. A bicoronal skin incision was made and then a bifrontal bone flap was made eccentric to the left. The patient had a high and large frontal sinus and it was necessary to enter the frontal sinus during the course of exposure. The frontal sinus was then stripped of mucosa and the ostea of the frontal sinus were fused with bone dust. The cranial posterior wall of the frontal sinus was removed thereby cranializing the sinus. The sinus was obliterated with biologic glue and Gelfoam. It was then covered with a vascularized pericranial flap that was harvested from the scalp flap. The dura was opened in a circumferential manner around the tumor. Tumor itself was extraaxial and appeared to be arising from the falx at the junction of the falx and skull base. The border of the tumor was developed and the falx sectioned after the superior sagittal sinus had been ligated in that area. The tumor and its dural origin were removed as a single piece. Immaculate hemostasis was achieved. The dura was repaired with a dural graft. The bone plate was securely plated in place and the remainder of the wound was dried and closed in layers over a Jackson-Pratt drain and a dry sterile dressing applied.
Thank you,
Joanne