Question

Discussion Question: Amy underwent burr hole surgery for biopsy of an intracranial lesion. The surgeon, Dr. Stanley, had to perform an abscess drainage of a cyst that was found during the procedure next to the lesion. Would the drainage of the cyst be reported separately from the biopsy code? Explain your answer in detail.

Answer 1

A burr hole procedure is a neurosurgical procedure wherein a hole is drilled through the skill to evacuate contents such as subdural hematomas, fluid, cysts, samples for biopsy, etc. The contemplated procedure is a biopsy of an intracranial lesion however, there is an incidental intraoperative finding of an abscess. The drainage of the cyst and the intracranial lesion biopsy shall have its separate report as well as a histopathology form. Take note that the neurosurgeon shall ask for consent to the nearest relative of the patient before proceeding with the abscess drainage; this is to prevent potential lawsuits.