The patient had a history of temporal bone fracture and has now developed meningoencephalic herniation and cerebrospinal fluid (CSF) otorrhea, with conductive hearing loss. He was admitted and underwent craniotomy, skull-based repair of the meningoencephalic herniation defect and CSF leak, with split-thickness graft, using calvarial bone and temporalis fascia, harvesting of bone and fascia for grafting, and placement of titanium microplates. During the surgery, intra-operative nerve monitoring was performed. What are the appropriate diagnosis and procedure code assignments?
Assign code 348.4, Compression of brain, as the principal diagnosis for the meningoencephalic herniation. Brain herniation is an inclusion term under code 348.4. Assign codes 388.61, Cerebrospinal fluid otorrhea, 389.00, Conductive hearing loss, unspecified, and 905.0, Late effect of fracture of skull and face bones, as additional diagnoses.
For the procedures, assign codes 02.04, Bone graft to skull, for the calvarial bone graft; 02.12, Other repair of cerebral meninges, for the repair of the CSF leak; 83.82, Graft of muscle or fascia; 02.05, Insertion of skull plate, for the placement of the titanium microplates; 77.79, Excision of bone for graft, other; 83.43, Excision of muscle or fascia for graft, for the harvesting of bone and fascia; and 00.94, Intra-operative neurophysiologic monitoring.