Variations in Current Procedural Terminology Coding for Craniofacial Surgery: A Need for Review and Change.

BACKGROUND: A survey was utilized to study the coding practices of surgeons performing craniofacial procedures, in order to determine whether coding for these procedures might be standardized or expanded. METHODS: An online survey was designed with 6 sample cases to cover a variety of procedures encountered in the field of craniofacial surgery which was sent to members of 3 professional organizations centered around the practice of craniofacial/maxillofacial surgery. Surgeons were asked to read the vignettes and choose from a series of multiple-choice responses to code the cases, or write in their own response. Codes were based on the American Medical Association current procedural terminology listings. Responses were compiled and tabulated. RESULTS: One hundred twenty-eight people initiated the survey. The largest common coding responses for each vignette were selected by 45.2% of respondents for the case describing placement of an internal mandibular distractor; 45.3% for the case of scaphocephaly remodeling; 67.1% for a case of cranioplasty for trigonocephaly; 47.2% for hypertelorism repair with periorbital osteotomies; 60% for LeFort III advancement with external distractors; and 53.6% for the case describing the removal of an internal mandibular distractor. Between 4 and 12 codes were identified for possible use in each clinical scenario. CONCLUSION: There appears to be wide variability among those who routinely perform craniofacial surgery as to the appropriate ways to code these procedures. We hope to bring this to the attention of coding committees for further discussion to hopefully bring about more accurate and descriptive codes for craniofacial surgical procedures.

Neuroembryology and functional anatomy of craniofacial clefts.

The master plan of all vertebrate embryos is based on neuroanatomy. The embryo can be anatomically divided into discrete units called neuromeres so that each carries unique genetic traits. Embryonic neural crest cells arising from each neuromere induce development of nerves and concomitant arteries and support the development of specific craniofacial tissues or developmental fields. Fields are assembled upon each other in a programmed spatiotemporal order. Abnormalities in one field can affect the shape and position of developing adjacent fields. Craniofacial clefts represent states of excess or deficiency within and between specific developmental fields. The neuromeric organization of the embryo is the common denominator for understanding normal anatomy and pathology of the head and neck. Tessier's observational cleft classification system can be redefined using neuroanatomic embryology. Reassessment of Tessier's empiric observations demonstrates a more rational rearrangement of cleft zones, particularly near the midline. Neuromeric theory is also a means to understand and define other common craniofacial problems. Cleft palate, encephaloceles, craniosynostosis and cranial base defects may be analyzed in the same way.

Prolonged success with a covered endovascular stent after emergent use in radiation-induced subclavian artery blowout: a case report.

Radiation-induced damage to the bone, soft tissues, and vasculature represents the unfortunate consequences of radiation therapy for the treatment of malignant tumors. Complications arising from irradiation are frequently challenging to manage and may be life threatening. A case is presented of a patient with a longstanding clavicular osteoradionecrosis with an acute massive hemorrhage after rupture of the subclavian artery and subsequent management with endovascular stent placement. With over 2 years' follow-up, vascular patency was maintained with no further bleeding episodes in this surgically high-risk patient.

Mitochondrial toxicity in fetal Erythrocebus patas monkeys exposed transplacentally to zidovudine plus lamivudine.

This study was designed to investigate fetal mitochondrial toxicity in Erythrocebus patas monkeys exposed in utero to zidovudine (AZT) and lamivudine (3TC), and taken at term. Pregnant patas monkeys were given a daily dose of 40 mg AZT (86% of the human daily dose, based on body weight), for the last 10 weeks (50%) of gestation, and a daily dose of 24 mg 3TC (84% of the human daily dose, based on body weight) for the last 4 weeks of gestation. At term, AZT was found to be incorporated into fetal mitochondrial DNA from skeletal muscle, liver, kidney, and placenta. By transmission electron microscopy (EM) drug-exposed fetal cardiac and skeletal muscle cells showed mitochondrial membrane compromise, mitochondrial proliferation, and damaged sarcomeres, while mitochondria in brain cerebrum and cerebellum were morphologically normal. Substantial depletion of oxidative phosphorylation (OXPHOS) Complex I specific activities was observed in heart (87% reduction in mean, p = 0.02) and skeletal muscle (98% reduction in mean, p = 0.002) from drug-exposed fetuses, compared to unexposed fetuses. In addition Complex IV activity was highly depleted (85% reduction in mean, p = 0.004) in skeletal muscle from the drug-exposed fetuses (p = 0.004). Brain cerebrum and cerebellum showed no statistically significant OXPHOS changes with drug exposure. Mitochondrial DNA quantity was substantially depleted (>50%) in heart, skeletal muscle, cerebellum, and cerebrum from drug-exposed fetuses compared to unexposed controls. Overall, the data indicate that significant mitochondrial damage was observed at birth in monkey fetuses exposed in utero to AZT plus 3TC in a human-equivalent dosing protocol.