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Field Guide to Physician Coding 3rd Edition


Forum Discussion Areas > Ask Us a Question > Sinus Surgery through Craniotomy -- CPT 31085 ?
  Sinus Surgery through Craniotomy -- CPT 31085 ?
Sinus Surgery through Craniotomy -- CPT 31085 ?
Jul 22 2010, 9:21 AM
Below is the OP notes. Please help to find the CPT code. Is 31085 justified?

POSTOPERATIVE DIAGNOSIS: Ruptured posterior wall of the frontal sinus.

OPERATIONS PERFORMED: Craniotomy for exenteration of a frontal sinus along with harvesting and use of a vascularized pericranial graft.


DISPOSITION: The patient was transferred in stable condition to the ICU.

SUMMARY: The patient was brought to the operating room and underwent uneventful intubation. Preoperative dose of mannitol, steroids, and antibiotics was given. The patient time-out was performed. The patient was placed with the Mayfield pins up. A curvilinear ??<__________> superior incision was planned based on the patient's preoperative wishes which he did not wish for a Z incision. The patient was then prepped in the usual fashion including alcohol, followed by chlorhexidine, followed by DuraPrep, all of them x2. The patient was draped in the usual sterile fashion. Local anesthetic was used to anesthetize the skin. A 15-blade was used to score the epidermis. I then used snaps to be able to split the skin and galea from the pericranium. Using that technique, I was able to open the incision without injuring the pericranium. A pericranial ??<__________> graft was elevated, first using the monopolar to Bovie the periphery and then elevating with a periosteal elevator. A pericranial flap had been injured in the area of his previous injury and was repaired using 3-0 Vicryl. Of note is that subperiosteal dissection was then carried down all the way to the orbital rims. The skin was then flapped down and held in place with hooks and of note is that underneath the skin I had placed Kerlixes that were bunched up into cigars in order to avoid any acute angles at the skin of the forehead and avoid any closure of that skin. The periphery was then covered with Ray-Tecs which were kept moist during the entire case. Following that, 2 bur holes were created on the right and on the left and the AM-8 was used to drill a burr off the central part of the calvaria to avoid any injury to the sinus. A periosteal elevator was used to elevate the dura. A router was then used to go ahead and elevate the bone flap. This did come across the sinus anterior and posterior wall as expected. Following that, the bone flap, I went ahead and removed the posterior wall of the sinus from the bone flap and went ahead and used the high-speed drill to drill away the entire surface of the remaining anterior surface of the frontal sinus that was on the bone flap in order to remove all mucus-producing cells. This was done with a high-speed drill. Of note is that the correction of the anterior deficit was performed by Plastic Surgery. Following that, I went ahead and placed tack-up sutures around the periphery of the craniotomy, waxed the bony bleeding and went ahead and placed both FloSeal and Surgicel around the gutters and tacked it up with tack-up sutures. Following that, I went ahead and exenterated the sinus by removing the posterior wall of the sinus using the Leksell and the high-speed drill. This actually had surprisingly large nasal frontal ducts and as seen by the preoperative CAT scan had pneumatized orbital rims for walls. For that reason, extensive removal of the posterior wall was performed, leaving a very small ledge all the way in the back in order to be able to anchor the material with which I would pack the nasal frontal sinus. After I was satisfied with the resection of the posterior wall, I went ahead and then used the diamond drill to again drill off all cells producing any mucus in order to avoid a mucocele formation in the future. This was done using a high-speed drill and no irrigation so that I could constantly see where I had previously drilled. Very careful attention was made to not skip or miss any point with the drilling with the high-speed diamond drill. I was very satisfied with the cleaning of the sinus.

Of note is that prior to that, I had stripped any of the obvious sinus mucosa using a periosteal freer and had packed it down marsupializing it into the nasal frontal duct. Of note is that there was no evidence of any leakage of CSF from any areas of the dura. Following that, I went ahead and packed the nasal frontal duct with Gelfoam that had been soaked in antibiotic bacitracin ointment. I went ahead and then imbricated the pericranial graft inwards, packing it down into the nasal frontal duct. I used a parachute technique in order to secure it down deep into the dura. 4-0 Nurolon was used for that reason. This was done in order to imbricate the pericranial graft down into the nasal frontal duct and to the area where the previous sinus existed. This was done again using a parachute technique. At that point, I inspected for any bleeding, and any bleeding was controlled using bipolar cautery. The remainder of the operation, including the replacement of the craniotomy and the closure, was performed by Plastic Surgery. Of note is that I did place 2 tack-up stitches on the dura centrally which Plastic Surgery would tent up through the craniotomy once they replaced it. The patient tolerated my part of the procedure with no complications.


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