Question

FIGURE 12-8 CASE 12-4 Operative Report, Craniotomy The removal of this tumor is conducted through a bone flap. LOCATION Inpatient Hospital PATIENT Arlene Samuels ATTENDING PHYSICIAN Timothy Pleasant, MD SURGEON Timoth Pleasant MD PREOPERATIVE DIAGNOSIS Right temporal parietal frontal brain tumor POSTOPERATIVE DIAGNOSIS Glioblastoma multiforme PROCEDURE PERFORMED: Osteoplastic craniotomy with removal of tumor in temporal lobe frontal lobe, and middle cerebral artery complex contiguous laining sites ANESTHESIA: General PROCEDURE Under general anesthesia, the patient's head was prepped and draped in the usual manner. A question mark incision was made in the front of the ear up to the frontal area. The skin flap was turned down. The temporalis muscle was incised. We then did an osteoplastic craniotomy with burr holes and craniotome. The flap was turned. The dura was incised. We then made an incision into the superior temporal lobe. The plan was to resect the temporal lobe get into the tumor and stay away from the middle cerebral concler and also to decompress her on the frontal lobe as well since the tutto was going into the frontale. I got into the tumor and sent specimen for biopsy and then began the gradual dissection. I encountered some bleeding, probably from middle cerebral artery branches. I had to take a few with silver clips, perhaps two to three. Otherwise, we left the syvian vein intact and decompressed the area (decompression is bundled into tumor removall. We got into the tumor cavity and took as much visual tumor as we could. The bed was then dried. I irrigated the wound well. I placed a piece of Gelfoam over the raw surface of the brain and began closure of the dura with 3-0 Vicryl. The bone flap was replaced with two straight four-holed Wurzburg plates. Hemovac was placed, and the scalp was closed in layers utilizing 3-0 Vicryl on the galea with surgical staples on the skin. Dressing was applied. The patient was discharged to PAH (postanesthesia recoveryl Pathology Report Later indicated: Glioblastoma multiforme SERVICE CODES) 10-10-CM DX COUESE

Can you help me find the Service code and ICD 10CM code(s). Rationale reasoning of why the codes are used.

Answer 1

Service code: 61510-RT

ICD-10-CM-DX code: C71.2, C71.1

Rationale:

The procedure was the removal of a brain tumor using a bone flap. So it is coded as 61510. The procedure takes place on the right side of the temporal bone. So the modifier -RT is used. A biopsy was collected and the report shows Glioblastoma multiforme which was in temporal bone and going into the frontal bone. So the code C71.2, C71.1 is used.