clwilliamson
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I have this coded as 61582, 61600-51, 62140, 61782. Can anyone give some input on this? Thanks!
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, and was placed on the OR table in the
supine position. Head was turned to the right side. After induction of general anesthesia, the head was placed in 3-point
fixation. The fiducials were registered into the Stealth Guidance machine. Afterwards, the hair was clipped over the left side
of the head, Then, after prepping the skin of the scalp, an incision was made in a C-shaped fashion along the left
fronto-temporal area. Incision was carried down to the bone. the subgaleal tumor was dissected, exposing the bony edges
along the fronto-temporal bone. the lateral orbital rim was exposed: it was already destroyed by the tumor that was removed,
allowing a fronto-orbital approach, Then the periorbita was dissected . Using Stealth, the extra dural tumor was localized.
The tumor was exposed. The tumor was found to be extra-axial We followed the tumor margin all the way circumferentially,
and dissected free form the surrounding tissue, including the skin, the surrounding fronto-temporal bone and dura, as well as
the periorbita. Then the tumor was resected piecemeal. It was felt that we achieved adequate resection using direct
inspection and frameless guidance for localization. We then proceeded with achieving adequate hemostasis, which was
achieved. A fronto-temporal cranioplasty was performed using a titanium mesh, secured with screws. the lateral orbital rim
was reconstructed using a titanium miniplate for the bone, 2-0 Polysorb for the galea and staples for skin, after leaving a
subgaleal drain. Dressing was applied. The patient was then extubated and taken to the recovery room in good condition.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, and was placed on the OR table in the
supine position. Head was turned to the right side. After induction of general anesthesia, the head was placed in 3-point
fixation. The fiducials were registered into the Stealth Guidance machine. Afterwards, the hair was clipped over the left side
of the head, Then, after prepping the skin of the scalp, an incision was made in a C-shaped fashion along the left
fronto-temporal area. Incision was carried down to the bone. the subgaleal tumor was dissected, exposing the bony edges
along the fronto-temporal bone. the lateral orbital rim was exposed: it was already destroyed by the tumor that was removed,
allowing a fronto-orbital approach, Then the periorbita was dissected . Using Stealth, the extra dural tumor was localized.
The tumor was exposed. The tumor was found to be extra-axial We followed the tumor margin all the way circumferentially,
and dissected free form the surrounding tissue, including the skin, the surrounding fronto-temporal bone and dura, as well as
the periorbita. Then the tumor was resected piecemeal. It was felt that we achieved adequate resection using direct
inspection and frameless guidance for localization. We then proceeded with achieving adequate hemostasis, which was
achieved. A fronto-temporal cranioplasty was performed using a titanium mesh, secured with screws. the lateral orbital rim
was reconstructed using a titanium miniplate for the bone, 2-0 Polysorb for the galea and staples for skin, after leaving a
subgaleal drain. Dressing was applied. The patient was then extubated and taken to the recovery room in good condition.