Please, any help with this would be greatly appreciated. The physician gave me code 61343 for this, but I think if this was used I would have to use a reduced service modifier on this. If not then an unlisted code which is where I'm leaning more towards. I've never had him go back in after doing the chiari decompression for the graft being infected and needing to be removed.
OPERATIVE PROCEDURE: Re-exploration of Chiari decompression with removal of bovine pericardium graft.
We reopened his previous incision with a 15 blade and this was carried down through the soft tissues. We used the Bovie to open the midline cervical musculature. It was fairly scarred in to this point. We were able to identify the edge of the craniectomy and then the lamina of C2 bilaterally. There was a lot of soft tissue in the epidural space and we carefully dissected through this until we found the bovine pericardial graft. This was removed both by just pulling it out, which most came out and then having to excise portions of it as well with scissors. We achieved good hemostasis. We then closed with #2-0 PDS in the deep musculature followed by a running #2-0 PDS on the fascia and then a running #3-0 Vicryl in the fascia. We then placed some #3-0 Vicryl in the deep dermal layer and then a #5-0 Monocryl through and through on the skin with Dermabond. Patient tolerated procedure well and was transferred to the PICU in stable condition.
OPERATIVE PROCEDURE: Re-exploration of Chiari decompression with removal of bovine pericardium graft.
We reopened his previous incision with a 15 blade and this was carried down through the soft tissues. We used the Bovie to open the midline cervical musculature. It was fairly scarred in to this point. We were able to identify the edge of the craniectomy and then the lamina of C2 bilaterally. There was a lot of soft tissue in the epidural space and we carefully dissected through this until we found the bovine pericardial graft. This was removed both by just pulling it out, which most came out and then having to excise portions of it as well with scissors. We achieved good hemostasis. We then closed with #2-0 PDS in the deep musculature followed by a running #2-0 PDS on the fascia and then a running #3-0 Vicryl in the fascia. We then placed some #3-0 Vicryl in the deep dermal layer and then a #5-0 Monocryl through and through on the skin with Dermabond. Patient tolerated procedure well and was transferred to the PICU in stable condition.