beastman1
New
This case came up in Practicode. I'm a very new CPC-A and any help is appreciated determining correct coding. Thank you!
PROCEDURES: RIGHT CRANIOPLASTY WITH WIRE MESH AND METHYL METHACRYLATE.
POSTOPERATIVE DIAGNOSIS: RIGHT CRANIAL DEFECT.
INDICATIONS: The patient is a middle-aged man with history of previous severe head injury that required the craniotomy and removal of the bone flap in order to provide room for the brain to swell. The patient remained in a vegetative state postoperatively. He was brought to the clinic for further management of his cranial defect. In order to prevent possible further injury of the brain our recommendation was to perform the cranioplasty. The nature of the procedure as well as indications possible benefits and possible complications were explained to the patient's family to their understanding. They were insisting that they wanted the procedure to be done and the patient was scheduled for surgery as described.
PROCEDURE: The patient was brought into the operating room and transferred to the operating table. General anesthesia was induced and he was placed on respirator. The site of the previous craniotomy incision was then carefully prepped and draped in usual fashion.
Using a scalpel the previous surgical incision was re-incised. Subcutaneous tissues were divided with unipolar cautery and great care was taken at all points not to penetrate or lacerate the covering of the brain. Once the incision had been completed skin flap was carefully elevated from the underlying pseudodura and scar that was overlying the brain. Planes between skin and pseudodura was carefully divided with use of the unipolar cautery. The fraction of skin flap was transected away from the underlying of pseudodura and the brain at this point still remained unexposed. The brain was bulging somewhat through the craniotomy incision at this point. In order to prevent the brain from bulging a small incision was made on the pseudodura with a #11 scalpel and a small ventricular catheter was introduced through it into the ventricles.
Approximately 25 cc of cerebrospinal fluid was removed and in doing so the brain carefully receded and pulled away providing a flat surface on which the cranioplasty was to be placed. The edges of the cranial defect were carefully exposed by removing scar tissue from it with the use of a
small curette.
A wire mesh of the appropriate shape and size was then brought into the operating field and carefully shaped to provide covering of the brain. The wire mesh was then reattached to the surrounding scope with the use of mini screws which were held in place. We then mixed methylmethacrylate used for cranioplasty and once the appropriate consistency was obtained it was poured over the wire mesh leaving a small hole through which the epidural space was decompressed. It was copiously irrigated while it hardened to carry away any piece that was generated in the process.
Once the methylmethacrylate had hardened we irrigated the entire surgical site with warm saline and with bacitracin solution prior to the closure. The skin flap was brought back to its original orientation and the closure was performed by reapproximating edges of galea with 3-0 Vicryl. The skin edges were brought together with skin staples. Upon conclusion the incision was cleaned with Betadine and sterile dressing was applied in a sterile fashion.
PROCEDURES: RIGHT CRANIOPLASTY WITH WIRE MESH AND METHYL METHACRYLATE.
POSTOPERATIVE DIAGNOSIS: RIGHT CRANIAL DEFECT.
INDICATIONS: The patient is a middle-aged man with history of previous severe head injury that required the craniotomy and removal of the bone flap in order to provide room for the brain to swell. The patient remained in a vegetative state postoperatively. He was brought to the clinic for further management of his cranial defect. In order to prevent possible further injury of the brain our recommendation was to perform the cranioplasty. The nature of the procedure as well as indications possible benefits and possible complications were explained to the patient's family to their understanding. They were insisting that they wanted the procedure to be done and the patient was scheduled for surgery as described.
PROCEDURE: The patient was brought into the operating room and transferred to the operating table. General anesthesia was induced and he was placed on respirator. The site of the previous craniotomy incision was then carefully prepped and draped in usual fashion.
Using a scalpel the previous surgical incision was re-incised. Subcutaneous tissues were divided with unipolar cautery and great care was taken at all points not to penetrate or lacerate the covering of the brain. Once the incision had been completed skin flap was carefully elevated from the underlying pseudodura and scar that was overlying the brain. Planes between skin and pseudodura was carefully divided with use of the unipolar cautery. The fraction of skin flap was transected away from the underlying of pseudodura and the brain at this point still remained unexposed. The brain was bulging somewhat through the craniotomy incision at this point. In order to prevent the brain from bulging a small incision was made on the pseudodura with a #11 scalpel and a small ventricular catheter was introduced through it into the ventricles.
Approximately 25 cc of cerebrospinal fluid was removed and in doing so the brain carefully receded and pulled away providing a flat surface on which the cranioplasty was to be placed. The edges of the cranial defect were carefully exposed by removing scar tissue from it with the use of a
small curette.
A wire mesh of the appropriate shape and size was then brought into the operating field and carefully shaped to provide covering of the brain. The wire mesh was then reattached to the surrounding scope with the use of mini screws which were held in place. We then mixed methylmethacrylate used for cranioplasty and once the appropriate consistency was obtained it was poured over the wire mesh leaving a small hole through which the epidural space was decompressed. It was copiously irrigated while it hardened to carry away any piece that was generated in the process.
Once the methylmethacrylate had hardened we irrigated the entire surgical site with warm saline and with bacitracin solution prior to the closure. The skin flap was brought back to its original orientation and the closure was performed by reapproximating edges of galea with 3-0 Vicryl. The skin edges were brought together with skin staples. Upon conclusion the incision was cleaned with Betadine and sterile dressing was applied in a sterile fashion.
So I am working on this case in Practicode right now and this is how I coded the ICD section of the case: