Help - with this surgery


Burkburnett, TX
Best answers
Could someone please help me with this surgery? The physician and I are having major differences of opinions over how this should be coded.

He coded it as 61684, surgery of infracranial AV malformation; infratentorial and 69990.

I was looking at either 61510 and/or 61518 with the 69990 pending edits.

PREOPERATIVE DIAGNOSIS: Left occipital lobe and cerebellar mass; status post
stereotactic irradiation of superior cerebellar artery arteriovenous
malformation; cerebral edema; severe headache.

POSTOPERATIVE DIAGNOSIS: Left occipital lobe and cerebellar mass; status post
stereotactic irradiation of superior cerebellar artery arteriovenous
malformation; cerebral edema; severe headache.

PROCEDURE: Left occipital craniotomy with excisional biopsy of cerebellar and
occipital lobe lesion, and use of surgical microscope.

PROCEDURE NOTE: The patient was brought to the operating room and placed
under general endotracheal anesthesia, Foley catheter inserted, SCD hose
applied, and appropriate IV lines started. He was rolled in the prone
position on two gel rolls. His head was turned so as to gain access to the
left postauricular and suboccipital region. His head was fixated in
three-point Mayfield-Keys fixation device. The scalp was prepped and draped
routinely. A linear skin incision was made halfway between the mastoid tip
and the inion. Suboccipital muscles subperiosteally dissected from the
suboccipital area. The approximate level of the transverse sinus was
delineated by skull landmarks. An osteoclastic craniotomy was performed with
the perforator and pneumatic craniotome abridging the transverse sinus. It
was necessary to excise a bit more of the suboccipital squamous bone with a
Leksell rongeur to get sufficient craniotomy opening. I first made a linear
incision in the dura paralleling the transverse sinus in the supratentorial
compartment. I identified the tentorial dura and gently lifted the occipital
lobe. The brain was somewhat swollen despite the use of 75 grams of mannitol.
At this point, I simply packed in several cottonoid patties to gently
displace the occipital lobe from the floor, using the slow plastic deformation
of the brain in order to gain access. After packing in 6-7 of these, I turned
my attention to the infratentorial compartment. I made a linear dural
incision paralleling the transverse sinus in the subtentorial area. The
cerebellum was also rather taut against the dura. I simply slipped down to
pierce the arachnoid of the cisterna magna to release spinal fluid. Doing
this maneuver, I had progressive relaxation of the cerebellar hemisphere that
allowed me to gain access to the superior aspect of the cerebellum against the
tentorium. At this time I brought in the surgical microscope and used it
throughout the remainder of the dissection. I sacrificed a small bridging
rather persistent or constant bridging vein between the superior cerebellum
and the transverse sinus and had free access to the superior aspect of the
cerebellar hemisphere. There were no actual visible lesions that I could see
on the superior cerebellar surface. At this time, I made an incision in the
cerebellar hemisphere with bipolar cautery and began exploring for the lesion.
Within about 0.5 cm, I soon began to encounter abnormal tissue. It had a
firm purplish hue. It was not particularly vascular. I surmised this was
probably the lesion that had been depicted by the MRI scan. I began biopsy of
this. Tactically, it had a slightly gritty feel with my biopsy forceps. I
removed the lesion in total, extending all the way over till I could encounter
the medial portion of the cerebellar hemisphere. The lesion was submitted to
the pathologist. He froze a bit of this and stated that it looked like
hyalinized blood vessels and did not see evidence of neoplasia. Bleeding from
this area was really not that problematic and controlled with bipolar cautery,
FloSeal, or Gelfoam/thrombin tamponade. Because this was radiated tissue, I
took extra time and care to assure adequate hemostasis from that dissection
bed. I placed some tamponade cottonoid patties onto Gelfoam thrombin and then
turned my attention back to the supratentorial compartment. By this time,
there had been plastic deformation of the occipital lobe and I was able to
lift it gently and identify a lesion in the inferior aspect of the occipital
lobe. I have biopsied this also, then obtained hemostasis rather easily. At
this time the case was concluded. Because this was irradiated tissue, I took
extra time to assure adequate hemostasis, having the nurse anesthetist provide
several rounds of Valsalva in order to increase venous pressure to check for
breakthrough venous bleeding and there was none. Once satisfied with
hemostasis, I placed a single layer of Surgicel over the dissection bed. I
closed each dural incision with 4-0 Nurolon suture. I replaced my craniotomy
with the Stryker cranial plates. Soft tissue hemostasis was achieved with
monopolar or bipolar cautery. I did opt to place a deep drain and bring it
out through a separate stab incision. I closed the muscular fascia with
interrupted Vicryl suture, the galea with interrupted Vicryl suture, and then
stapled the skin closed. The patient was rolled back supine, awakened from
anesthesia, and transported to the intensive care unit in stable condition.
From what I can tell from the dictation, it does look like he is removing abnormal blood cells which would be an AVM, as a matter of fact, the path report says it is not a neoplasm, it is abnormal blood cells. I agree with the surgeon, 61684. I dont see documentation of the microscope, the 69990.