lcole7465
Expert
I need some help on coding this procedure. The provider performed a laminectomy T1-T3 and resection of intradural extramedullary meningioma with operative microscope. Below is a copy of the op note. I', leaning more towards: CPT: 63271; ASA: 00620.
"The skin was incised with a #10 blade knife and dissection was carried out down to
and through the fascia with Bovie electrocautery. The paraspinal musculature was
elevated from its medial attachments and retracted laterally. We worked to create
an exposure that involved the entirety of the T1 through T3 lamina. A spinal needle
was then placed at the pedicle entry point for what was felt to be the 2nd thoracic
vertebra and another AP fluoroscopic image was obtained to confirm localization.
This confirmed that we were in fact at T2 and attention was then turned to
performing the laminectomy. The laminectomy was carried out from the inferior
aspect of T3 up through the roughly inferior 50% of the 1st thoracic lamina. We
left the superior portion of the 1st thoracic lamina and its ligamentous attachments
to C7 intact. Once laminectomy was completed using electric drill and Kerrison
rongeurs, the epidural space was packed with thrombin Gelfoam powder and the
operative microscope was brought onto the field for the intradural portion of the
procedure.
The intradural portion including resection of the tumor was carried out with
microscopic guidance with microsurgical technique. The dura was opened with #15
blade knife. At the superior aspect of our dural opening, we appeared to be coming
down into the tumor and it was difficult to identify a good plane, so the dura was
then opened from inferiorly where we were able to clearly visualize the arachnoid.
Dental instrument was then passed under the dura and was able to create a plane
between the dura and the tumor. The dura was opened in a midline longitudinal
incision with #15 blade knife. The dura was retracted using tack-up sutures. We
were able to identify the tumor quite easily that was nearly filling the canal, that
appeared to be adherent to the right aspect of the thecal sac. We were able to take
several small sections, which were sent for frozen specimen. During the remainder
of the dissection, the frozen pathology was reported as meningioma. This was
consistent with the appearance of the tumor and its attachment to the dura. The
tumor was debulked somewhat with Sonopet and dissection was carried out around the
plane, which was very clean with Rhoton micro dissectors. We worked primarily from
the inferior margin of the tumor dissecting it free from some arachnoid adhesions to
the right side of the nerve roots. The cord was able to be left essentially
undisturbed. The tumor was gradually debulked and mobilized until it was removed
entirely. Several large sections were able to be saved and sent for permanent
specimen. All the specimens were labeled to intradural thoracic tumor. Once the
tumor was out, the intradural space was copiously irrigated with plain saline. It
appeared that there was a small hemorrhage from the dural edge of the superior
aspect of the dural opening and this was coagulated with bipolar electrocautery.
The intradural space was again copiously irrigated and hemostasis appeared to be
pristine. At this point, attention was turned to closing. The dura was closed with
a running 4-0 Nurolon suture. It was reinforced with the length of DuraGen and
DuraSeal. Hemostasis was obtained as necessary with bipolar electrocautery and
thrombin Gelfoam powder. The wound was copiously irrigated and then closed in
layers with interrupted 0 Vicryl suture in the muscles and separately in the fascia.
An inverted interrupted 2-0 Vicryl layer was placed in the subcutaneous fat and the
dermis was closed with inverted interrupted 3-0 Vicryl suture. The skin was closed
with a skin stapler. The wound was cleaned and dried and dressed with bacitracin
and a bordered gauze dressing. The patient was returned to the supine position and
extubated in the operating room without incident. All sponge, instrument, and
needle counts were correct at the conclusion of the case. Neuromonitoring remained
stable throughout the procedure. The patient was taken to Recovery in stable
condition without evidence of complication. Ms. Kindred was present and scrubbed
for the entire procedure and assisted in all aspects of the case including opening,
maintaining exposure during the dissection and cleaning the instruments during the
decompression or retraction during the tumor debulking and resection and closing the
wound."
"The skin was incised with a #10 blade knife and dissection was carried out down to
and through the fascia with Bovie electrocautery. The paraspinal musculature was
elevated from its medial attachments and retracted laterally. We worked to create
an exposure that involved the entirety of the T1 through T3 lamina. A spinal needle
was then placed at the pedicle entry point for what was felt to be the 2nd thoracic
vertebra and another AP fluoroscopic image was obtained to confirm localization.
This confirmed that we were in fact at T2 and attention was then turned to
performing the laminectomy. The laminectomy was carried out from the inferior
aspect of T3 up through the roughly inferior 50% of the 1st thoracic lamina. We
left the superior portion of the 1st thoracic lamina and its ligamentous attachments
to C7 intact. Once laminectomy was completed using electric drill and Kerrison
rongeurs, the epidural space was packed with thrombin Gelfoam powder and the
operative microscope was brought onto the field for the intradural portion of the
procedure.
The intradural portion including resection of the tumor was carried out with
microscopic guidance with microsurgical technique. The dura was opened with #15
blade knife. At the superior aspect of our dural opening, we appeared to be coming
down into the tumor and it was difficult to identify a good plane, so the dura was
then opened from inferiorly where we were able to clearly visualize the arachnoid.
Dental instrument was then passed under the dura and was able to create a plane
between the dura and the tumor. The dura was opened in a midline longitudinal
incision with #15 blade knife. The dura was retracted using tack-up sutures. We
were able to identify the tumor quite easily that was nearly filling the canal, that
appeared to be adherent to the right aspect of the thecal sac. We were able to take
several small sections, which were sent for frozen specimen. During the remainder
of the dissection, the frozen pathology was reported as meningioma. This was
consistent with the appearance of the tumor and its attachment to the dura. The
tumor was debulked somewhat with Sonopet and dissection was carried out around the
plane, which was very clean with Rhoton micro dissectors. We worked primarily from
the inferior margin of the tumor dissecting it free from some arachnoid adhesions to
the right side of the nerve roots. The cord was able to be left essentially
undisturbed. The tumor was gradually debulked and mobilized until it was removed
entirely. Several large sections were able to be saved and sent for permanent
specimen. All the specimens were labeled to intradural thoracic tumor. Once the
tumor was out, the intradural space was copiously irrigated with plain saline. It
appeared that there was a small hemorrhage from the dural edge of the superior
aspect of the dural opening and this was coagulated with bipolar electrocautery.
The intradural space was again copiously irrigated and hemostasis appeared to be
pristine. At this point, attention was turned to closing. The dura was closed with
a running 4-0 Nurolon suture. It was reinforced with the length of DuraGen and
DuraSeal. Hemostasis was obtained as necessary with bipolar electrocautery and
thrombin Gelfoam powder. The wound was copiously irrigated and then closed in
layers with interrupted 0 Vicryl suture in the muscles and separately in the fascia.
An inverted interrupted 2-0 Vicryl layer was placed in the subcutaneous fat and the
dermis was closed with inverted interrupted 3-0 Vicryl suture. The skin was closed
with a skin stapler. The wound was cleaned and dried and dressed with bacitracin
and a bordered gauze dressing. The patient was returned to the supine position and
extubated in the operating room without incident. All sponge, instrument, and
needle counts were correct at the conclusion of the case. Neuromonitoring remained
stable throughout the procedure. The patient was taken to Recovery in stable
condition without evidence of complication. Ms. Kindred was present and scrubbed
for the entire procedure and assisted in all aspects of the case including opening,
maintaining exposure during the dissection and cleaning the instruments during the
decompression or retraction during the tumor debulking and resection and closing the
wound."
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