Gemini18
Expert
This is my first time coding for Neurology and I need some assistance. Here is the Op note:
PROCEDURES PERFORMED:
1. Right craniotomy for elevation and repair of depressed comminuted open
skull fracture.
2. Primary repair of dural rent.
FINDINGS: There was a dural tear underlying the depressed skull fracture.
Contused and friable brain was noted at the fracture site. Multiple bone
fragments where depressed into the brain substance.
OPERATIVE REPORT: The patient was brought to the operating room where smooth
induction of general anesthesia occurred. The patient received preoperative
antibiotics. She was placed in a 3-point Mayfield head fixator and positioned
with all pressure points appropriately padded.
The area was then prepped and draped in a sterile fashion. The scalp was
infiltrated with local anesthesia. A horizontal curvilinear incision was
made incorporating the existing laceration. The soft tissue and muscle were
retracted. The depressed fracture was noted immediately underlying the
incision. Using a curette, the free bone fragments were elevated. A small
craniotomy was turned with a craniotome to remove the remaining fragment. A
small amount of epidural hematoma was evacuated. The wound was copiously
irrigated with antibiotic solution. A dural rent was noted and examination of
the underlying brain through this revealed contusion. The brain was coagulated
to achieve hemostasis. The dura was then repaired in a primary fashion with 4-
0 silk suture.
Attention was then turned to the bony fragments, which were repaired with a
Syntheses plate and screw system. Hemostasis was achieved and the repaired bone
flap was replaced. The wound was irrigated again with antibiotic solution and meticulous hemostasis was obtained in the soft tissue and muscle.
The scalp was then closed in layers with interrupted 2-0 Vicryl and staples on
the skin. The lacettaion was closed with 4-0 nylon horizontal mattress sutures.
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I'm looking at 62010 and 61304 -- I just need to know if I'm on the right path.