How would you code this one?
DX 228.02
CPT???? 61684?
POSTOPERATIVE DIAGNOSIS:
Left middle cerebellar peduncle cavernoma with hemorrhage.
PROCEDURES PERFORMED:
1. Midline suboccipital craniotomy.
2. Telovelar approach to the left middle cerebellar peduncle and evacuation
of hematoma and resection of cavernoma.
3. Intraoperative mapping of the fourth ventricular floor.
DESCRIPTION OF PROCEDURE:
After the risks, benefits and alternatives were explained to the patient and
the family, written informed consent was obtained. The patient was brought in
the operating room on a gurney and transferred onto a bed. Satisfactory
general endotracheal anesthesia was then induced. After the ET tube and lines
were secured, the patient's head was fixed in a Mayfield skull clamp and he
was gently turned prone onto gel rolls.
He was taken out of the gel rolls. At this point the surgical site area was
then shaved, prepped and draped in a sterile fashion. After the draping was
done, linear incision was given from just above the superior nuchal line all
the way down to the C2 spinous process, and sharp dissection was done to
expose the suboccipital bone. We then placed 2 bur holes on either side and
turned the craniotomy flap. After the flap was elevated, we used an
ultrasound and noticed that the craniotomy was enough and C1 posterior arch
did not need to be taken out.
We then opened the dura in a Y-shaped fashion, let CSF out; and after the CSF
was drained, we noticed that the floor of the fourth ventricle was easily
visualized. At this point we dissected in the left tonsil area, and the
tonsil was elevated up and laterally. The PICA was dissected away in all
directions. We then opened the lateral aspect of the inferior medullary velum
and the superior medullary velum. We then noted there was an outpouching
lateral to the facial colliculus of the hematoma. We stimulated on the
surface and noticed that there was no facial activity. We then dissected down
and encountered cavernoma-related blood right underneath the peel. After the
blood was all drained out, we noticed a cavernoma was seen which was gently
dissected in all directions, coagulated and resected. We were able to _____
in all directions. We then irrigated the wound with copious amounts of saline
and achieved hemostasis.
We then laid a piece of Surgicel in the resection cavity and achieved dural
closure using 4-0 Vicryl stitches, and we needed to use a Durepair patch. We
then applied DuraSeal to that margin. The bone flap was replaced using the
Synthes craniofacial system. Then wound was irrigated with copious amounts of
saline, and closure was then done in layers using 2-0 Vicryl for the fascia
and subcutaneous tissue and 3-0 nylon for the skin. There were no
intraoperative complications. Sponge and needle counts x2 at the end of the
procedure were correct.
DX 228.02
CPT???? 61684?
POSTOPERATIVE DIAGNOSIS:
Left middle cerebellar peduncle cavernoma with hemorrhage.
PROCEDURES PERFORMED:
1. Midline suboccipital craniotomy.
2. Telovelar approach to the left middle cerebellar peduncle and evacuation
of hematoma and resection of cavernoma.
3. Intraoperative mapping of the fourth ventricular floor.
DESCRIPTION OF PROCEDURE:
After the risks, benefits and alternatives were explained to the patient and
the family, written informed consent was obtained. The patient was brought in
the operating room on a gurney and transferred onto a bed. Satisfactory
general endotracheal anesthesia was then induced. After the ET tube and lines
were secured, the patient's head was fixed in a Mayfield skull clamp and he
was gently turned prone onto gel rolls.
He was taken out of the gel rolls. At this point the surgical site area was
then shaved, prepped and draped in a sterile fashion. After the draping was
done, linear incision was given from just above the superior nuchal line all
the way down to the C2 spinous process, and sharp dissection was done to
expose the suboccipital bone. We then placed 2 bur holes on either side and
turned the craniotomy flap. After the flap was elevated, we used an
ultrasound and noticed that the craniotomy was enough and C1 posterior arch
did not need to be taken out.
We then opened the dura in a Y-shaped fashion, let CSF out; and after the CSF
was drained, we noticed that the floor of the fourth ventricle was easily
visualized. At this point we dissected in the left tonsil area, and the
tonsil was elevated up and laterally. The PICA was dissected away in all
directions. We then opened the lateral aspect of the inferior medullary velum
and the superior medullary velum. We then noted there was an outpouching
lateral to the facial colliculus of the hematoma. We stimulated on the
surface and noticed that there was no facial activity. We then dissected down
and encountered cavernoma-related blood right underneath the peel. After the
blood was all drained out, we noticed a cavernoma was seen which was gently
dissected in all directions, coagulated and resected. We were able to _____
in all directions. We then irrigated the wound with copious amounts of saline
and achieved hemostasis.
We then laid a piece of Surgicel in the resection cavity and achieved dural
closure using 4-0 Vicryl stitches, and we needed to use a Durepair patch. We
then applied DuraSeal to that margin. The bone flap was replaced using the
Synthes craniofacial system. Then wound was irrigated with copious amounts of
saline, and closure was then done in layers using 2-0 Vicryl for the fascia
and subcutaneous tissue and 3-0 nylon for the skin. There were no
intraoperative complications. Sponge and needle counts x2 at the end of the
procedure were correct.