As most medical practices are aware, not all cases are easy to navigate using the latest medical standards. The information below highlights a complicated surgical case along with the correct CPT and ICD-10 codes. Do you have a complicated surgery case need help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nn— Click Here To Submit Redacted Surgery Case Study —nn
nn63709-78, 69990nG96.0, G97.41nnSURGEON: J. Smith, MD.nASSISTANT SURGEON: N. Smith, RNFAnANESTHESIOLOGIST: N/AnPREOPERATIVE DIAGNOSIS: Postoperative CSP leak.nPOSTOPERATIVE DIAGNOSIS: Postoperative CSF leak.nOPERATIVE PROCEDURE: Re-exploration of lumbar wound and repair of CSF leak.nImplications: NonenESTIMATED BLOOD LOSS: 20mLnn
HISTORY OF PRESENT ILLNESS: A 36-year-old female who underwent a revision microdiskectomy for disk reherniation at which point there was an incidental durotomy. The patient developed evidence of CSF leakage including positional headaches. She was treated with 2 blood patches and the patient seemed to improve. Subsequently, she developed a collection under her skin. This was tapped, demonstrating clear fluid consistent with CSF. Given this and the failure of blood patch for treatment of CSF leak, the patient was brought to the OR for direct repair of the CSF leak. The patient understood the risks of surgery including bleeding, infection, continued CSF leak, need for future operation, and agreed to undergo the operation.nnPROCEDURE IN DETAIL: The patient was brought to the OR, placed under general endotracheal anesthesia. She was flipped into the prone position on a Jackson table, prepped and draped in the usual fashion. The previous small incision on the left side of the back over the lumbar spine was opened with a 10 blade until clear fluid was reached. The fluid was drained, and there was a large cavity consistent with a pseudomeningocele left. The tubular retractor system was then placed down over the previous laminotomy at the site of probable CSF leak. The microscope was brought in. The durotomy and leaking CSF was easily identified, and scar tissue was carefully separated from the dura. Further laminotomy was also performed to provide room for suturing the leak. Once this was complete, a 5-0 Prolene suture was used to suture the dura back together. Valsalva after the initial closure demonstrated l area of leakage. A fat graft was then obtained from the patient’s subcutaneous fat layers, and this was sewn into the leakage area. Subsequent Valsalva maneuver did not demonstrate any leakage of CSF. Given this, it was felt that the repair was adequate to stop the CSF leak. A piece of DuraGen was then placed over the exposed dura, and DuraSeal was placed over the DuraGen. Steroids were also placed over the dura. Prior to placement of the DuraGen, the wound was thoroughly irrigated, and hemostasis was achieved with bipolar cautery and Gelfoam powder. Next, the tubular retractor system was removed. The pseudomeningocele tissue was cut away from the normal tissue using monopolar cautery and removed from the patient. Hemostasis was then achieved with bipolar cautery. Attention was then turned to closure. A watertight closure was performed in the fascial layer using 0 Vicryl sutures. Next attempts were made to close down any potential space between the fascia and fat layer using 0 Vicryl sutures. The fat layer was also reapproximated with 0 Vicryl sutures. Finally, the deep dermal layer was closed with 0 Vicryl sutures and the skin was closed with a running subcuticular Monocryl. Dermabond was placed over the wound. The patient was then flipped into the supine position, extubated, and transferred to the PACU.