bgbarrett
Contributor
Any advice coding would be appreciated. I'm leaning towards 62010 but I'm not sure if that includes the craniotomy?
1. craniotomy for repair of skull fracture 2. repair of dural tear
A bicoronal incision was drawn out and a strip of hair was shaved. The bifrontal area was then cleaned with alcohol, prepped with betadine scrub and paint and draped in the usual sterile fashion. The incision was opened with a scalpel and continued with cautery. The pericranium was noted to be torn by the right frontal fracture. therefore a pericranial flap with a pedicle in the left frontal area was procured.. this was stripped toward the left side taking care to avoid tears and maintain the pedicle. Anteriorly, the pericranium was stripped from the right frontal orbit, taking care to avoid injury to the supraorbital neurovascular bundle. The periorbita was also stripped free. The nasofrontal and fronto-zygomatic sutures were exposed. the orbital rim was fully disconnected at the medial aspect just lateral to midline. there is a diastatic fracture through the frontozygomatic suture. A bifrontal craniotomy was drawn out, from just posterior to the coronal suture laterally just below squamosal on the right and anteriorly leaving approximately 1cm for the orbital rim. the craniotomy was taken approx 1cm to the left of midline. Several burr holes were made in order to strip the dura free and then a router with footplate was used to create the craniotomy. The dura was stripped free with a penfield 3. There were several fracture fragments in the temporal area below the squamosal suture. these were removed and reconnected to the main craniotomy bone with sutures. this was set aside for closure. There was a large dural tear noted on the medial posterior aspect of the orbital roof related to a displaced fracture fragment. This was closed in a primary fashion using 4-0 nurolon. a water tight closure was obtained. Hemostasis was obtained and a large sheet of surgicel was placed over the brain. Dr. X then performed the repair of orbital fractures which will be dictated separately. The bone was replaced with absorbable sutures.
1. craniotomy for repair of skull fracture 2. repair of dural tear
A bicoronal incision was drawn out and a strip of hair was shaved. The bifrontal area was then cleaned with alcohol, prepped with betadine scrub and paint and draped in the usual sterile fashion. The incision was opened with a scalpel and continued with cautery. The pericranium was noted to be torn by the right frontal fracture. therefore a pericranial flap with a pedicle in the left frontal area was procured.. this was stripped toward the left side taking care to avoid tears and maintain the pedicle. Anteriorly, the pericranium was stripped from the right frontal orbit, taking care to avoid injury to the supraorbital neurovascular bundle. The periorbita was also stripped free. The nasofrontal and fronto-zygomatic sutures were exposed. the orbital rim was fully disconnected at the medial aspect just lateral to midline. there is a diastatic fracture through the frontozygomatic suture. A bifrontal craniotomy was drawn out, from just posterior to the coronal suture laterally just below squamosal on the right and anteriorly leaving approximately 1cm for the orbital rim. the craniotomy was taken approx 1cm to the left of midline. Several burr holes were made in order to strip the dura free and then a router with footplate was used to create the craniotomy. The dura was stripped free with a penfield 3. There were several fracture fragments in the temporal area below the squamosal suture. these were removed and reconnected to the main craniotomy bone with sutures. this was set aside for closure. There was a large dural tear noted on the medial posterior aspect of the orbital roof related to a displaced fracture fragment. This was closed in a primary fashion using 4-0 nurolon. a water tight closure was obtained. Hemostasis was obtained and a large sheet of surgicel was placed over the brain. Dr. X then performed the repair of orbital fractures which will be dictated separately. The bone was replaced with absorbable sutures.
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