I am stuck on what cpt code to use for this operative report! This is a co-surgery and I am coding for the second surgeon. The patient had a left ethmoid lesion, the first surgeon went in and removed the lesion. The second surgeon then entered the field and did a transnasal endoscopic resection and repair of the dura. I am not sure what code to use for transnasal endoscopic resection and repair of dura.
The answer to this question depends on who is doing the repair and what is being repaired. Is it a Neurologist (I am assuming if he is repairing the derma)? Is there a leak of cerebral fluid? was there s tissue graft? Is so look at Codes in the 60000 "Base of Posterior Cranial Fossa Procedures" series to determine an appropriate code, Be sure to watch for the approach. Check out61618 to see if it fits the service provided.
61618 - Secondary repair of dura for cerebrospinal fluid leak, anterior, middle or posterior cranial fossa following surgery of the skull base; by free tissue graft (eg, pericranium, fascia, tensor fascia lata, adipose tissue, homologous or synthetic grafts)