Jaslene08
Guest
Hello- I billed 61571 for the op note below - Can you please advise if this is the correct code?
POSTOP DIAGNOSES: 1. Status post gunshot wound to the left parietal region. 2. Depressed skull fracture fragments. 3. Concern for left parietal intracranial abscess. 4. Left parietal scalp subcutaneous abscesses.
PROCEDURE PERFORMED: Irrigation debridement of left scalp, elevation and removal of depressed skull fracture fragments, evacuation of left intracranial/intra-axial abscess, removal of foreign objects.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative theater and was intubated by Anesthesia. All appropriate lines were placed. SCDs were placed on the bilateral lower extremities. IV antibiotics were started 30 minutes prior to incision. The patient had been given mannitol 75 g prior to beginning the surgery in addition to the antibiotics noted above. The patient's pCO2 was also lowered to the mid 20s to low 30s during the surgery. The patient was already on anti-epileptic medication prior to the surgery which was last given in close proximity to the operation. The patient was turned 180 degrees away from anesthesia. The patient was positioned supine with head resting on gel donut. The right side of the head was positioned down. The left side of the head was positioned up. Hair overlying the left side of the head was shaved. The left side of the patient's head was prepped and draped in the usual sterile fashion. Time-out was performed prior to the operation. Lidocaine 1% with epinephrine was injected into the planned incision site. The planned incision was marked to begin along the left frontoparietal region close to the midline and extending back toward the posterior parietal region near the midline as well. Incision was carried out with the use of a 10 blade. Raney clips were applied to the skin edges for hemostasis. Bovie cautery was used to dissect down through the galea down to the periosteum. Subperiosteal dissection was carried out laterally bilaterally. Care was taken during this process given the depressed fracture fragments previously noted. Care was taken to remain on bone with cautery for safe, adequate exposure. Adequate exposure was able to be performed to reveal the fracture fragments noted on the preoperative scans. The fracture fragments were removed safely and dissected away from the underlying brain tissue using a Penfield 1. All the fracture fragments that were mobile were removed successfully without any complication. Care was especially taken near the sagittal sinus with the fracture fragments noted along that location. Of note, there was noted to be abnormal appearing tissue in between the fracture fragments which appeared consistent with an abscess. Pus was noted within the brain that was cultured. Cultures were also obtained in the epidural space x2 and sent for the standard cultures. The abnormal appearing tissue was aspirated. All tissue that appeared consistent with abscess was aspirated/removed. Otherwise, the rest of the underlying brain appeared pulsatile. The underlying brain was found to be relaxed. No abnormal bleeding was encountered. Adequate hemostasis obtained in the epidural/subdural spaces. The dura had been previously torn from the mechanism of the trauma. No actual bullet fragments were visualized. There was what was felt to be a bullet fragment that was palpated medially, although given its close proximity to the sinus, this was not investigated further. Certainly, there would be concerns with regard to causing significant bleeding if attempting to remove that fragment. The wound was then irrigated copiously with antibiotic wash. Adequate hemostasis had been obtained. A medium Hemovac drain was left in the epidural space and tunneled medially and secured with 2- 0 nylon stitch. The wound was then closed in layers. The galea was closed with interrupted 2-0 Vicryl stitches. Skin was closed with staples. Of note, a 3-0 Vicryl suture was placed to close the hole directly overlying the left parietal wound which was the initial entrance site of the bullet. There appeared to be a communication between the abnormal appearing tissue/abscess along the left parietal scalp region that appeared to communicate with the intracranial abscess that was also visualized intraoperatively. All sponge and needle counts were correct x2. I was present and scrubbed for the entire surgery. The patient's mother and the rest of the family were updated both over the telephone and in person following surgery. SPECIMEN: Epidural cultures x2 and intracranial abscess cultures x1 sent for standard cultures. Culture was sent on one of the skull fracture fragments. All of the skull fracture fragments except one of the skull fracture fragments were sent for pathology
POSTOP DIAGNOSES: 1. Status post gunshot wound to the left parietal region. 2. Depressed skull fracture fragments. 3. Concern for left parietal intracranial abscess. 4. Left parietal scalp subcutaneous abscesses.
PROCEDURE PERFORMED: Irrigation debridement of left scalp, elevation and removal of depressed skull fracture fragments, evacuation of left intracranial/intra-axial abscess, removal of foreign objects.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative theater and was intubated by Anesthesia. All appropriate lines were placed. SCDs were placed on the bilateral lower extremities. IV antibiotics were started 30 minutes prior to incision. The patient had been given mannitol 75 g prior to beginning the surgery in addition to the antibiotics noted above. The patient's pCO2 was also lowered to the mid 20s to low 30s during the surgery. The patient was already on anti-epileptic medication prior to the surgery which was last given in close proximity to the operation. The patient was turned 180 degrees away from anesthesia. The patient was positioned supine with head resting on gel donut. The right side of the head was positioned down. The left side of the head was positioned up. Hair overlying the left side of the head was shaved. The left side of the patient's head was prepped and draped in the usual sterile fashion. Time-out was performed prior to the operation. Lidocaine 1% with epinephrine was injected into the planned incision site. The planned incision was marked to begin along the left frontoparietal region close to the midline and extending back toward the posterior parietal region near the midline as well. Incision was carried out with the use of a 10 blade. Raney clips were applied to the skin edges for hemostasis. Bovie cautery was used to dissect down through the galea down to the periosteum. Subperiosteal dissection was carried out laterally bilaterally. Care was taken during this process given the depressed fracture fragments previously noted. Care was taken to remain on bone with cautery for safe, adequate exposure. Adequate exposure was able to be performed to reveal the fracture fragments noted on the preoperative scans. The fracture fragments were removed safely and dissected away from the underlying brain tissue using a Penfield 1. All the fracture fragments that were mobile were removed successfully without any complication. Care was especially taken near the sagittal sinus with the fracture fragments noted along that location. Of note, there was noted to be abnormal appearing tissue in between the fracture fragments which appeared consistent with an abscess. Pus was noted within the brain that was cultured. Cultures were also obtained in the epidural space x2 and sent for the standard cultures. The abnormal appearing tissue was aspirated. All tissue that appeared consistent with abscess was aspirated/removed. Otherwise, the rest of the underlying brain appeared pulsatile. The underlying brain was found to be relaxed. No abnormal bleeding was encountered. Adequate hemostasis obtained in the epidural/subdural spaces. The dura had been previously torn from the mechanism of the trauma. No actual bullet fragments were visualized. There was what was felt to be a bullet fragment that was palpated medially, although given its close proximity to the sinus, this was not investigated further. Certainly, there would be concerns with regard to causing significant bleeding if attempting to remove that fragment. The wound was then irrigated copiously with antibiotic wash. Adequate hemostasis had been obtained. A medium Hemovac drain was left in the epidural space and tunneled medially and secured with 2- 0 nylon stitch. The wound was then closed in layers. The galea was closed with interrupted 2-0 Vicryl stitches. Skin was closed with staples. Of note, a 3-0 Vicryl suture was placed to close the hole directly overlying the left parietal wound which was the initial entrance site of the bullet. There appeared to be a communication between the abnormal appearing tissue/abscess along the left parietal scalp region that appeared to communicate with the intracranial abscess that was also visualized intraoperatively. All sponge and needle counts were correct x2. I was present and scrubbed for the entire surgery. The patient's mother and the rest of the family were updated both over the telephone and in person following surgery. SPECIMEN: Epidural cultures x2 and intracranial abscess cultures x1 sent for standard cultures. Culture was sent on one of the skull fracture fragments. All of the skull fracture fragments except one of the skull fracture fragments were sent for pathology