PROCEDURAL NOTE
PATIENT: Lopez, Olga
AGE: 76 years
DATE: 11/05/2014
PATIENT DIAGNOSIS: Multiple Skull Lymphoma
PROCEDURE: Craniotomy converted to craniectomy of left anterior cranial base
ANESTHESIA: General endotracheal
The patient was placed in supine position on operating table and anesthesia was successfully administered. The patient was prepped in the usual manner. An incision was made on the midline of the patient’s anterior cranial base and the surgeon dissected the epidermal layer to reveal the skull. Three .2 to .4 cm lymphomas were located and the skull bone was excised in one piece to remove the affected are as leaving a .1 cm margin. Halfway through the procedure the patient’s blood pressure dropped. It was difficult to control throughout the remaining procedure. Due to the patient’s drop in blood pressure, the surgeon decided to convert the procedure to a craniectomy, so that bone grafts were not placed. A drain was placed beneath the remaining skull base and the edges of the skin were then sutured back together using 4-0 vicryl sutures. A sterile dressing was placed on the excision site. The patient was removed from endotracheal anesthesia and remained under physician supervision until her blood pressure stabilized. The patient was taken to the recovery room and scheduled for a bone graft at a later date. What is the correct code for this surgery?
