The surgeon perfoms a craniectomy for an intracranial abscess on the left side of the cerebellum and performs the drainage. The surgeon creates a burr hole over the right side of the cerebellum and implants an intracranial pressure recording device. A 3 cm x 5 cm fascia graft is obtained from the patient's thigh and is used to temporarily close the cranium. So far I have 61320 and 61210 but not feeling to confident and feel that I am missing more codes.
I am new at this and very nervous.
Look at 20920-20922 for the separate fascia graft.
You might want to attend an American Association of Neurological Surgeons (AANS) coding course. We at KZA are on the faculty. For more information, go to: http://aans.org/en/Education%20and%20Meetings/Education%20Programs/~/media/Files/Education%20and%20Meetingf/Education%20Courses/2011CodingCourseList.ashx
You might also want to sign up for the KZAlerts at www.karenzupko.com as we send out the answers to frequently asked neurosurgery coding questions on a regular basis.
Kim Pollock, RN, MBA, CPC
KarenZupko & Associates, Inc.
If it is a CEREBELLAR abscess then the appropriate crani code would be an infratentorial code (61321). Since the ICP device was placed through a separate burhole then 61210-59 can be reported. If deep fascia from the thigh was harvested then this would be reported with 20920-20922 (I would need to see the procedure note to determine which would be appropriate, or you can ask the surgeon).
If those are the only procedures reported then you are not missing any codes.
What about the sequencing of this code set? Does 61321 come first? Also, I thought the ICP placement would be 61107. The abscess was on the left side of the brain and the burr hole for the measuring device is on the right side. 61210 says burr hole with aspiration of hematoma or cyst, but the cyst was on the other side of the brain. As for the graft, it only says "a 3 cm x 5 cm fascia graft is obtained fromt he patient's thigh and is used to temporarily close the cranium."