Tumor resection and CSF leak
All the sudden we have an outbreak of..... brain tumors 
We are trying to review procedures more closely that we used to in I-9 to make sure PCS info is included. But what is coming up frequently is when complications should be coded on these records. I am hoping someone with more neuro experience can help.
1. Transsphenoidal endoscopic resection of pituitary adenoma: There was appearance of egressive CSF from the top corner. Once tumor was resected, a piece of Gelfoam was placed into the top corner in the sella itself, and it seemed to abate the egressive CSF. DuraSeal was then placed over the posterior wall and injected over the posterior wall, and there seemed to be good occlusion of the posterior wall with the DuraSeal with no evidence of egressive CSF.
2. Endoscopic endonasal resection of pituitary tumor: Once it was felt that complete tumor resection had been achieved, an abdominal fat graft was obtained. The fat graft was placed intrasellar. The nasoseptal flap that was obtained by Dr. Tritle and will be dictated separately, was then placed into the sphenoid sinus, and the sellar defect was then covered. Repair of the dura was then finalized using Tisseel. )" Repair of CSF leak with endonasal flap, Tisseel and abdominal fat graft." Listed as a procedure)
3. Microsurgical resection of intratentorial meningioma:" The dura attachment of the tumor was meticulously bipolared with bipolar cautery. The sinus was repaired using TISSEEL, SYNTHECEL and 4-0 Nurolon sutures. The dura defect and attachment of the tumor was removed completely with the tumor and was repaired utilizing SYNTHECEL, DuraGen and TISSEEL." ("Repair of CSF leak with SYNTHECEL, DuraGen, TISSEEL." Listed as a procedure)
When I attempt to code a CSF leak I end up with G9782 and G960 but I am not sure. Is documentation clear enough to consider these complications? Do some/all require queries? Of course all say there were 'no complications' at the end of the OP note.
Thanks in advance for your help!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
We are trying to review procedures more closely that we used to in I-9 to make sure PCS info is included. But what is coming up frequently is when complications should be coded on these records. I am hoping someone with more neuro experience can help.
1. Transsphenoidal endoscopic resection of pituitary adenoma: There was appearance of egressive CSF from the top corner. Once tumor was resected, a piece of Gelfoam was placed into the top corner in the sella itself, and it seemed to abate the egressive CSF. DuraSeal was then placed over the posterior wall and injected over the posterior wall, and there seemed to be good occlusion of the posterior wall with the DuraSeal with no evidence of egressive CSF.
2. Endoscopic endonasal resection of pituitary tumor: Once it was felt that complete tumor resection had been achieved, an abdominal fat graft was obtained. The fat graft was placed intrasellar. The nasoseptal flap that was obtained by Dr. Tritle and will be dictated separately, was then placed into the sphenoid sinus, and the sellar defect was then covered. Repair of the dura was then finalized using Tisseel. )" Repair of CSF leak with endonasal flap, Tisseel and abdominal fat graft." Listed as a procedure)
3. Microsurgical resection of intratentorial meningioma:" The dura attachment of the tumor was meticulously bipolared with bipolar cautery. The sinus was repaired using TISSEEL, SYNTHECEL and 4-0 Nurolon sutures. The dura defect and attachment of the tumor was removed completely with the tumor and was repaired utilizing SYNTHECEL, DuraGen and TISSEEL." ("Repair of CSF leak with SYNTHECEL, DuraGen, TISSEEL." Listed as a procedure)
When I attempt to code a CSF leak I end up with G9782 and G960 but I am not sure. Is documentation clear enough to consider these complications? Do some/all require queries? Of course all say there were 'no complications' at the end of the OP note.
Thanks in advance for your help!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
Comments
Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)
Robert S. Gold, MD
CEO, DCBA, Inc
4611 Brierwood Place
Atlanta, GA 30360
(770) 216-9691 (Office)
(404) 580-0204 (Cell)
I was suspicious that this was the case but lack neuro experience and was asked for help determining what is/is not a complication in these situations. What you are saying makes perfect sense. Thanks (again) for coming to my rescue!
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
AHIMA Approved ICD-10CM/PCS Trainer
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404