Would greatly appreciate advice on coding the below operative report. This was performed for Thalamic Neoplasm…I found CPT 0398T but it indicates it is for intracranial movement disorder so I do not believe that is correct. I also saw 61720 but unsure that this actually represents all aspects of the procedure.
Thank you in advance for any and all assistance!
PREOPERATIVE DIAGNOSIS: lt thalamic metasases
POSTOPERATIVE DIAGNOSIS: same
PROCEDURE:
Stereotactic localization including burr hole with insertion of laser catheter x2 for thermal ablation, magnetic resonance guidance for and monitoring of parenchymal tissue ablation of left basal ganglia neoplasm, creation of lesion by stereotactic method deep subcortical neoplasm left thalamic mass
INDICATION: history of breast CNS metastases sp whole brain and gamma knife radiosurgery here for thermal ablation of the left thalamic mass. Procedure and risks discussed. Procedure and risks were discussed with patient and family who did express understanding and agreement. Informed consent was signed and placed in the chart.
DESCRIPTION OF PROCEDURE: The patient was brought to the operative suite. The patient was positioned on the bed. Patient was verified. The patient was all ready intubated. All necessary lines were placed. Time out was called. Preoperative antibiotics were started. We proceeded to attach the Leksell head frame with good purchase.
We proceeded to bring the patient down for a head stereotactic protocol CT in order to fuse the stealth MRI done the night prior. The patient was brought back up to the OR suite and transferred to the operative table with all pressure points well padded. The images merged well.
The Leksell head frame was secured to the bed.
The planning images were transferred to the Stealth navigation system where two trajectories were created, one laterally directed lead and another medially directed lead. The coordinates were as follows:
Lateral lead:
Lat (x) +103.1
AP (y) +81.6
Vert (z) +128.8
Ring 110.7
Arc 59.7
Medial lead:
Lat (x) +103.6
AP (y) +88.6
Vert (z) +130.9
Ring 119.4
Arc 65.3
Entry and target points were marked.
We began with the more lateral lead.
The Arc was attached and set. The entry mark was set and a 15 blade was used to make a small incision. At the appropriate trajectory, through the reducing cannulas, the Salcman drill was used to puncuture through the skull. A spinal needle was used to puncture the dura.
The thermal guidance bolt was brought up into the field and was placed through the alignment rod and the bolt screwed into place with the trajectory locked. The alignment rod was removed.
We then proceeded to work on placing the more medial lead. The Arc was removed and the Y and Z axis points were set.
The Arc was attached and set. The entry mark was set and a 15 blade was used to make a small incision. At the appropriate trajectory, through the reducing cannulas, the Salcman drill was used to puncuture through the skull. A spinal needle was used to puncture the dura.
The laser catheters were placed through the guidance bolts without resistance to target (190cm). At this point, the laser catheters were secured and the drapes were removed. The patient was removed from the Leksell head frame and transferred to the stretcher.
Patient was brought to MRI for the 2nd portion of the procedure. In MRI, reference images were obtained. The laser catheters were noted to be in optimal position.
We again began with the more lateral lead. Treatment plan was created in a modified coronal and sagittal plane. High and low target limits were set. Visualase thermal therapy system was connected to the magnet and image transfer was initiated. Thermal sequences were identified. Phase refrence was set and a test dose was initially delivered at 4.5 W for 12 secs. The laser was noted to be in optimal position and initial burn was at 9.75W for 117 secs. The catheter was pulled back approximately 1-cm. We opted to deliver another burn at 9.75W for 27 secs. The catheter was pulled back approximately another 1-cm. We proceeded to deliver another burn at 9W for 25 secs. After another 5 mins, we proceeded to deliver a burn 7.5W for 42secs. The calculated additive treatment demonstrated a well circumscribed treatment in the coronal and sagittal view orthogonal to the lead.
We then used the more medial lead. Treatment plan was created in a modified coronal and sagittal plane. High and low target limits were set. Visualase thermal therapy system was connected to the magnet and image transfer was initiated. Thermal sequences were identified. Phase refrence was set and a test dose was initially delivered at 4.65 W for 21 secs. The laser was noted to be in optimal position and initial burn was at 9.75W for 100 secs. The catheter was pulled back approximately 1-cm. We opted to deliver another burn at 4.8W for 12 secs. The catheter was pulled back approximately another 1-cm. We proceeded to deliver another burn at 9.75W for 89 secs. The calculated additive treatment demonstrated a well circumscribed treatment in the coronal and sagittal view orthogonal to the lead.
The patient obtained routine post-ablation protocol images.
The catheters and bolts were removed and incision was closed with a 4-0 monocryl suture and skin glue. The patient was transferred back to the OR in stable condition