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Thread: Nuero-surgery

  1. #1
    Join Date
    Apr 2007

    Default Nuero-surgery

    AAPC: Back to School
    Please help me code the placement of bone flaps into the abd subcutaneous compartment or a code that comes close to it. I'm going to use and unlisted code for this portion of the surgery, but need a code description that comes close to it where I can change a few words and I will have my description for the unlisted code to send to my finance person to compare pricing. Thanks in advance for all your help in advance, here is the operative report:

    POSTOPERATIVE DIAGNOSIS: Malignant intracranial hypertension.

    1. Bilateral decompressive craniectomy with stellate opening of the dura.
    2. Revision of right external ventricular drain.
    3. Placement of bone flaps into the abdominal subcutaneous compartment.

    OPERATIVE FINDINGS: Pressure was significantly lower at the end of the

    COMPLICATIONS: A 1-cm corticectomy was made in the right frontal cortex
    upon opening the dura.


    INDICATIONS FOR PROCEDURE: This 10-year-old male had undergone a
    spontaneous intraventricular hemorrhage with hydrocephalus secondary to an
    arteriovenous malformation rupture 72 hours previously. Despite maximal
    aggressive medical management, his intracranial pressure continued to rise
    into the upper 30s and 40s. Emergency surgery to attempt to decompress the
    brain and brainstem was discussed at length with his mother. The risks of
    the decompressive craniectomy including death, infection, life-threatening
    bleeding, transfusion, damage to the brain, need for further surgery, and
    infection were discussed. She appeared to understand the procedure and
    risks and provided consent for surgery.

    PROCEDURE: The patient was brought emergently to the operating room. His
    head was placed on horseshoe headrest in the supine position. I then
    shaved, prepped and draped in the usual fashion after tying off the
    external ventricular drains, cutting the distal catheters, and discarding

    I made a bicoronal scalp incision and secured the edges with Raney clips.
    The scalp was reflected anteriorly toward the frontal bone. The
    ventriculostomy catheters were brought back through the scalp into direct
    vision. No drainage was noted out of the right ventricular catheter.
    Spontaneous pearly hemorrhagic spinal fluid was draining freely out of the
    left catheter.

    I made a bur hole 2.5 cm to the right of midline. The dura was stripped
    off the undersurface of the bone. A cranial router was then used to
    outline a large frontal parietal temporal bone flap leaving a tongue of
    bone on the right for the ventriculostomy catheter.

    I turned my attention to the left. Again, a single bur hole was made
    approximately 2.5 cm off of the midline. A small amount of venous bleeding
    was noted through the bur hole. This could not easily be controlled with
    bone wax. The dura was stripped from the undersurface of the bone. Again,
    the cranial router was used to outline a large frontal parietal temporal
    bone flap. Both bone flaps were elevated and the underlying dura stripped.
    Bone flaps were set aside in bacitracin-soaked laparotomy sponges.

    The right ventricular catheter was not draining. This was removed and
    replaced with a new Bactiseal ventricular catheter.

    I then opened a 15-cm transverse skin incision in the right upper quadrant.
    This was carried down to the anterior rectus sheath. A large subcutaneous
    pocket was then created. The pocket was irrigated with bacitracin saline
    followed by Betadine saline. The bone flaps were nestled together and then
    passed into the pocket. The Hemovac drain was placed underneath the bone
    flaps and brought out through a separate stab incision in the skin. This
    was connected to the drainage bulb. The incision was then closed in layers
    with interrupted Vicryl followed by running Monocryl for skin. A retention
    suture was placed at the drain site.

    The dura was elevated in the right frontal region and sharply incised.
    Cottonoids were used to protect the brain from the dural splinting
    incisions. It was noted after the dura was opened that a 1-cm corticectomy
    had been made in one of the right middle frontal gyri. The cortical veins,
    which were dark blue and showing evidence of stasis as well as the
    arteries, which were sluggishly pulsatile prior to dural opening became
    bounding after dural opening. Duragen was then placed over the exposed

    The venous lacune, which was identified on the left side, was controlled
    with Gelfoam, thrombin spray and gentle pressure. The left hemisphere dura
    was elevated, sharply incised and opened in a stellate fashion widely.
    Duragen was placed over the exposed brain. The scalp was reflected and the
    external ventricular drain was brought out through the stab incisions in
    the scalp. They were attached to their connectors. The catheters and
    connectors were secured to the scalp and to each other with silk ties and
    with nylon suture. A Hemovac drain was placed over the midline bone. It
    was secured to the scalp with a Vicryl suture. The scalp was then
    reapproximated with interrupted Vicryl followed by a running nylon skin
    suture. Antibiotic ointment and clean dressings were applied. A retention
    suture was placed to the drain. The external ventricular drains were set
    up. The suction balls were attached to each of the abdominal and cranial
    drains. Antibiotic ointment and clean dressings were applied. The drapes
    were removed. He was then moved to the ICU bed and taken to the ICU in
    critical condition. Needle and sponge counts were correct at the end of
    the case. Estimated blood loss was 300 cc.

  2. #2
    Join Date
    Apr 2007
    North Carolina


    Look at 61316...This is an "add on" code. What code did you select for "Bilateral decompressive craniectomy with stellate opening of the dura"?

    The retrieval of the grafts will be 62148

  3. #3
    Join Date
    Apr 2007


    So far I have 61322, 61322-50, 62225-51 and my last is the one on "creation of subcutaneous cavity in abd wall with implatation of cranial bone flaps" which I have not found a code for. But I will look into the code you suggested. Thanks.

  4. #4
    Join Date
    Apr 2007
    Milwaukee WI

    Default Unlisted

    I think you will need to use an unlisted code, 17999.

    What the surgeon is doing is creating a pocket in the subcutaneous abdominal wall so that the bone flaps he removed to relieve the intracranial pressure can be preserved for later replacement.

    I would consider this procedure (creating the subq pocket) akin to placing a tissue expander, CPT 11960 (work RVU 11.01)

    Check with your surgeon to be sure s/he thinks that procedure/pricing is in line with what s/he actually did.

    Hope that helps (Hope the patient is okay, too).

    F Tessa Bartels, CPC, CEMC

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