When your neurosurgeon performs a subdural tap in an infant as a diagnostic, stabilizing, or life-saving procedure, don’t focus on the intent of the tap but instead keep a count of the number of subsequent taps your surgeon performs to recoup all your earned reimbursement. “Subdural drainage in infants may require a series of percutaneous drainage taps to manage reaccumulation of the subdural fluid,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.
Use the op note that follows to guide your subdural tap coding:
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Operative note: “The child was placed in a supine position and secured in an immobilizer. All appropriate monitoring, ancillary personnel, and resuscitation equipment were confirmed. Small area of hair was clipped or shaved around the target site of the tap. The site of the tap was identified by locating the junction of the coronal and sagittal sutures where the coronal suture forms the lateral margin of the anterior fontanelle such that the puncture will be done in the most lateral aspect of the anterior fontanelle.
Using strict aseptic techniques, a subdural needle, 18 gauge, 1.5 inch spinal needle, was inserted at an angle of 90 degrees to the transverse plane of the skull through the stretched skin over the lateral margin of the anterior fontanelle. Care was taken to avoid the sagittal sinus. The needle was secured in the hand with heel...
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