antoniamay
Networker
Hello, I am new to Skull Based Surgery coding and am really confused on these cases. From the research I found I have seen I should be using 61526 instead of 61595 and 61616 for Vestibular Schwannoma's. The physician states the reason he is using 61595 and 61616 is the approach but to me it appears he is dissecting down to the mastoid cavity which would be the 61526? I am also wondering if it is possible to pick up the mastoidectomy.
DESCRIPTION OF PROCEDURE:
The patient was placed in supine position. He was orotracheally intubated and
induced under general anesthesia. The left temporal area was shaved, prepped, and
draped in a sterile fashion and injected with 1% lidocaine with 1:100,000 of
epinephrine. Orbicularis oculi and orbicularis auris myocutaneous electrodes were
placed on the left side for continuous facial nerve monitoring during the
procedure. The monitoring service was also used to monitor the lower cranial
nerves and perform whole-brain monitoring. A Foley catheter was placed and an
arterial line was placed at the beginning of surgery. A left postauricular C-
shaped incision works created by Dr. XXX, two fingerbreadths posterior to the
pinna and dissection was carried down to the mastoid cortex. A postauricular flap
was then elevated off the mastoid and reflected anteriorly and retracted out of
the field. Dr. XXX then performed an intact canal wall mastoidectomy. The
tegmen was maintained intact superiorly. The mastoid was well pneumatized.
Dissection was carried medially into the mastoid antrum and the horizontal canal
and short process of the incus were identified. Dissection was then performed
inferior to these 2 landmarks parallel to the course of the facial nerve in the
mastoid portion. The facial nerve was identified. The mastoid maintained covered
by a thin layer of bone. The posterior canal wall was thinned appropriately. The
labyrinthectomy was then performed beginning with the horizontal canal.
Dissection was then carried posteriorly to the posterior canal and medially to the
superior canal with removal of all semicircular canal contents. The internal
auditory canal was then skeletonized about a 200-degree circumference. Tumor was
encountered both superior and inferior to the internal auditory canal. An
eggshell layer of bone was removed off the internal auditory canal exposing the
IAC contents. The sigmoid sinus was then decompressed. The bone was then removed
from the posterior fossa dura. There was a small amount of bleeding from the
inferior aspect of the sigmoid sinus, which was controlled with thrombin-soaked
Gelfoam with excellent hemostasis achieved. The tumor was noted to be quite large
in the internal auditory canal expanding the IAC superiorly, laterally, and
inferiorly. I was able to stimulate the facial nerve at Bill's bar following at
the end of the approach. The sinodural angle was widely exposed. Dr. YYY then
scrubbed into the surgery and performed definitive removal of the vestibular
schwannoma. He will dictate this separately. Following removal of the
schwannoma, Dr. XXX did scrub back into the case. The incus was removed from the
attic and the tensor tympani tendon was transected. Multiple fascia graft was
then packed into the eustachian tube through the aditus to prevent postoperative
CSF leak. A large temporalis fascia graft was harvested to the superior aspect of
the postauricular incision with upper lateral cartilage scissors and placed into
saline bath. The right lower quadrant of the abdomen had been prepped at the
beginning of the surgery. Dr. XXX then performed an incision in the right lower
quadrant with a 15 blade. An abdominal fat graft was harvested with
electrocautery. The incision was reapproximated in 2 layers using 3-0 Vicryl for
the subcutaneous layer and 4-0 nylon in an interrupted fashion for reapproximation
of skin. Hemostasis was noted to be excellent. The abdominal fat graft was then
placed and cut into small strips for placement into the mastoid cavity. Noted
that the patient did receive 10 mg of Decadron at the onset of the surgery as well
as Ancef. A temporalis fascia graft was then packed into the depths of the
mastoid cavity and the mastoid was packed with abdominal strips and abdominal fat
in a layered fashion. Excellent venous pulsations were noted at the end of the
procedure. Cranioplasty was then performed by Dr. XXX with placement of a
titanium mesh over the lateral aspect of the mastoid cavity. This was secured
with 4 mm self-tapping bone screws superiorly, inferiorly, and posteriorly. The
postauricular incision was then reapproximated in 3 layers using 3-0 Vicryl for
the deep and subcutaneous layer and 4-0 nylon in a running interlocking fashion
for reapproximation of the skin. The ear canal was inspected at the end of the
procedure. The tympanic membrane was noted to be intact. A mastoid dressing was
then applied after bacitracin ointment was placed over the incision and the
patient was transferred to recovery room in stable condition. He tolerated the
procedure quite well.
Dr is wanting to bill - 61595-62, 61616-62, 15769, 15733, 62140, 95867-26, 69990
My suggestion on Codes - 61526-62, 15769, 15733, 69502. Removing 95867 and 69990 as inclusive.
Questions:
1. Is the correct approach on this note truly translabryinthe? Should it be 61526 or the 61616 and 61595?
2. Can you bill for the cranioplasty? I believe I need to query for size of defect to be better documented if so or is that inclusive to the procedure?
3. Would you add in the Mastoidectomy? Or is that inclusive to this procedure - there are no edits with 61526
DESCRIPTION OF PROCEDURE:
The patient was placed in supine position. He was orotracheally intubated and
induced under general anesthesia. The left temporal area was shaved, prepped, and
draped in a sterile fashion and injected with 1% lidocaine with 1:100,000 of
epinephrine. Orbicularis oculi and orbicularis auris myocutaneous electrodes were
placed on the left side for continuous facial nerve monitoring during the
procedure. The monitoring service was also used to monitor the lower cranial
nerves and perform whole-brain monitoring. A Foley catheter was placed and an
arterial line was placed at the beginning of surgery. A left postauricular C-
shaped incision works created by Dr. XXX, two fingerbreadths posterior to the
pinna and dissection was carried down to the mastoid cortex. A postauricular flap
was then elevated off the mastoid and reflected anteriorly and retracted out of
the field. Dr. XXX then performed an intact canal wall mastoidectomy. The
tegmen was maintained intact superiorly. The mastoid was well pneumatized.
Dissection was carried medially into the mastoid antrum and the horizontal canal
and short process of the incus were identified. Dissection was then performed
inferior to these 2 landmarks parallel to the course of the facial nerve in the
mastoid portion. The facial nerve was identified. The mastoid maintained covered
by a thin layer of bone. The posterior canal wall was thinned appropriately. The
labyrinthectomy was then performed beginning with the horizontal canal.
Dissection was then carried posteriorly to the posterior canal and medially to the
superior canal with removal of all semicircular canal contents. The internal
auditory canal was then skeletonized about a 200-degree circumference. Tumor was
encountered both superior and inferior to the internal auditory canal. An
eggshell layer of bone was removed off the internal auditory canal exposing the
IAC contents. The sigmoid sinus was then decompressed. The bone was then removed
from the posterior fossa dura. There was a small amount of bleeding from the
inferior aspect of the sigmoid sinus, which was controlled with thrombin-soaked
Gelfoam with excellent hemostasis achieved. The tumor was noted to be quite large
in the internal auditory canal expanding the IAC superiorly, laterally, and
inferiorly. I was able to stimulate the facial nerve at Bill's bar following at
the end of the approach. The sinodural angle was widely exposed. Dr. YYY then
scrubbed into the surgery and performed definitive removal of the vestibular
schwannoma. He will dictate this separately. Following removal of the
schwannoma, Dr. XXX did scrub back into the case. The incus was removed from the
attic and the tensor tympani tendon was transected. Multiple fascia graft was
then packed into the eustachian tube through the aditus to prevent postoperative
CSF leak. A large temporalis fascia graft was harvested to the superior aspect of
the postauricular incision with upper lateral cartilage scissors and placed into
saline bath. The right lower quadrant of the abdomen had been prepped at the
beginning of the surgery. Dr. XXX then performed an incision in the right lower
quadrant with a 15 blade. An abdominal fat graft was harvested with
electrocautery. The incision was reapproximated in 2 layers using 3-0 Vicryl for
the subcutaneous layer and 4-0 nylon in an interrupted fashion for reapproximation
of skin. Hemostasis was noted to be excellent. The abdominal fat graft was then
placed and cut into small strips for placement into the mastoid cavity. Noted
that the patient did receive 10 mg of Decadron at the onset of the surgery as well
as Ancef. A temporalis fascia graft was then packed into the depths of the
mastoid cavity and the mastoid was packed with abdominal strips and abdominal fat
in a layered fashion. Excellent venous pulsations were noted at the end of the
procedure. Cranioplasty was then performed by Dr. XXX with placement of a
titanium mesh over the lateral aspect of the mastoid cavity. This was secured
with 4 mm self-tapping bone screws superiorly, inferiorly, and posteriorly. The
postauricular incision was then reapproximated in 3 layers using 3-0 Vicryl for
the deep and subcutaneous layer and 4-0 nylon in a running interlocking fashion
for reapproximation of the skin. The ear canal was inspected at the end of the
procedure. The tympanic membrane was noted to be intact. A mastoid dressing was
then applied after bacitracin ointment was placed over the incision and the
patient was transferred to recovery room in stable condition. He tolerated the
procedure quite well.
Dr is wanting to bill - 61595-62, 61616-62, 15769, 15733, 62140, 95867-26, 69990
My suggestion on Codes - 61526-62, 15769, 15733, 69502. Removing 95867 and 69990 as inclusive.
Questions:
1. Is the correct approach on this note truly translabryinthe? Should it be 61526 or the 61616 and 61595?
2. Can you bill for the cranioplasty? I believe I need to query for size of defect to be better documented if so or is that inclusive to the procedure?
3. Would you add in the Mastoidectomy? Or is that inclusive to this procedure - there are no edits with 61526