Pterional Craniotomy Resection of Clinoidal Meningioma
What would be the CPT code for the above procedure? The surgeon doesn't mention skull base at all, so I don't think a skull based coding is correct, but I am not sure. Any help is greatly appreciated. Report is below. Thanks.
A 52-year-old patient came with a seizure and was found to have a very large paraclinoid meningioma with a massive mass effect with a tentorial herniation. I decided to take the patient to the OR to remove that lesion.
Pterional craniotomy resection of clinoidal meningioma.
DESCRIPTION OF PROCEDURE:
In the morning of 10/04/2017, the patient was brought to the OR after informed consent has been obtained, was placed in supine position after general endotracheal intubation, obtaining baseline electrophysiological monitoring. The patient's head was registered with good accuracy into the BrainLab navigation system. The landmark for a pterional craniotomy over the left side was marked on the skin with a thick marking pen. After meticulous prepping and draping, after giving prophylactic antibiotic, after giving of mannitol, Lasix and steroids and additional dose of Dilantin, the incision has been opened up with a skin knife, deepened down to the bone. The skin flap and the muscle flap was retracted anteriorly and inferiorly. It was connected with a surrounding drape with a combination of some fish hooks and hooks. Three bur holes were made. A very thick hyperostotic bone has been elevated. The sphenoid wing has been drilled and seen as much as possible. The dura was elevated and was connected to surrounding drapes. A large tumor was seen very stuck to the normal brain tissue. Surgical microscope was brought into the field, initially starting in the temporal area. It was then marked without difficulty. Plan has been opened in between the brain and the tumor that allowed for debulking of the tumor with a Sonopet which allowed for passing of cotton patties in between the brain and the tumor. The dissection continued all the way to the floor of the temporal fossa and to where the tip of the temporal lobe used to lay exposing the clinoid, exposing the sphenoid and allowing eventually for a removal and resection of all the tumor including resection of the tumor with a special tipped Sonopet away from the dura itself. The base at the top of the clinoid has been taken out with the help of a Penfield #1 and with Sonopet. At that point after the tumor was resected in a 360 fashion degree, based on navigation system resection seems to be complete. I could see the carotid artery at the bottom of the incision posteriorly. I would mention that a small branch coming out from the middle cerebral artery has been isolated and coagulated keeping the middle cerebral artery unchanged. I would also mention that electrophysiological monitoring during the case neither the somatosensory or the _____ 1 were changed. At that point, a count was showing that one cotton patty was missing. X-ray was brought into the picture and no evidence for the cottonoid was seen. The incision has gone through meticulous hemostasis, blood pressure for 120. The patient's head was closed with a combination of Duragen, his own bone with a couple of bur hole covers and with straight tissues. The skin and muscle has been closed on top of a medium Hemovac which was externalized through a separate stick incision. The patient had received sterile dressing. The patient's head will be removed from the Mayfield head holder and will be brought directly from OR into CT and in case that we are going to see some remaining cottonoid, the patient will be brought immediately to the OR for removal even though I doubt it.
This is what I found, if someone else has additional information please contribute,
The pterional craniotomy approach provides wide access to the skull base this was done for excision of a meningioma. Craniotomy involves creating scalp and bone flaps. The codes below are specifically associated with the excision of meningiomas.
61512 - Craniectomy, trephination, bone flap craniotomy; for excision of meningioma, supratentorial.
61519 - Craniectomy for excision of brain tumor, infratentorial or posterior fossa; meningioma
The difference between the above codes is the approach supratentorial: superior to the tentorium of the cerebellum, and infratentorial: subtentorial , posterior: situated in back of, or in the back part of a structure.