Wiki Surgery coding

sdunaway1

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Can an expert coder please look at the below coding and let me know if you agree w the codes chosen? THANK YOU SO MUCH!!!!!!

operation- L4-S1 LAMINECTOMY FOR DRAINAGE OF EPIDURAL ABSCESS AND DRAINAGE AND DEBRIDEMENT OF THE L5-S1

dx - L5-S1 EPIDURAL ABSCESS
PREVERTEBRAL ABSCESS W PROBABLE INFECTION
S1 SEGMENT OSTEOMYELITIS

I feel that we should go with- 63047, W NO 63048 FOR L4-5 AND 63267 FOR L5-S1

G06.1, M46.27, M46.47

The patient is a 49-year-old white male with approximately a month
history of gradually worsening low back pain. He has actually been in the Emergency
Department in the past and then was admitted on 10/14/2017 for pain management because of
severe low back pain. He subsequently spiked a fever. Cultures were carried out, which
showed gram-positive cocci in his blood. An MRI scan was then obtained with and without IV
contrast of the lumbar spine, which showed probable epidural abscesses as well as
prevertebral abscesses. Neurosurgery was consulted and based on the patient's elevated CRP,
white blood cell count, positive cultures and the findings on the MRI scan, I felt surgery
was necessary, namely an L4 to S1 decompressive laminectomy for drainage and culture of the
epidural abscesses.Preoperative MRI scan did not show evidence of significant enhancement
or fluid within the disc space at the L5-S1 level. I discussed the surgical procedure with
the patient. I explained the rationale as well as potential benefits and risks, including
potential risks of CSF leak, postoperative wound hematoma, possible increased pain,
weakness, and sensation loss in the right and/or left lower extremities after surgery, the
possibility of recurrence of the infection requiring debridement in the future, the
possibility of bowel or bladder dysfunction, the risks of general anesthesia including the
possibility of death. Mr. Cicero understood these risks and he did consent to surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room on a PR cart where
he underwent successful induction of general anesthesia and placement of an endotracheal
tube. Correct placement of the ET tube was checked by Anesthesia. When it was confirmed to
be in the correct position, the airway was secured. The patient was then maneuvered into a
prone position on a Wilson laminectomy frame and all pressure points were carefully checked
and padded. Skin overlying the lower lumbar spine was prepped and draped off in a sterile
manner using a double-glove technique. A midline incision was carried out extending from L4
down to S1, carried down sharply to the lumbodorsal fascia and then a bilateral
subperiosteal dissection along the lateral aspect of the spinous processes of L4, L5 and S1
was carried out bilaterally and then self-retaining retractors were placed. An x-ray was
carried out at the L5-S1 interspace and the x-ray indeed showed the marker at L5-S1 just
below the L5-S1 disc space as expected.
At this time, using a 10 blade, the interspinous ligaments were divided between L4 and L5
and between L5 and S1. The entire spinous process of L5 was removed, the inferior half of
L4 and the superior half of S1 was removed. Using the Midas Rex dissecting tool, the
lamina was drilled down to a thin eggshell of bone and then removed with Kerrison rongeurs,
exposing the epidural space. The thecal sac was under significant pressure and pushed
posteriorly. There was significant ligamentum flavum hypertrophy and this was decompressed,and the lateral recesses were decompressed. Just behind the L5 vertebral body just above the
L5-S1 disc space using a Crile dissector, we got into the epidural abscess, two fairly
discrete cavities and with pus under fairly high pressure; this was cultured and then
following the epidural abscessed down, it clearly communicated with the L5-S1 disc space,
which was full of a lot of purulence under significant pressure. This was irrigated out,
first with normal saline and then with chlorhexidine gluconate solution (Irrisept). The
L5-S1 disc space was debrided and decompressed using pituitary rongeurs and removing a lot
of degenerative infected disc material. I should mention that a culture was also taken from
the L5-S1 disc space. All these cultures were sent for Gram stain, aerobic and anaerobic
culture as well as fungal culture and mycobacterium. I also explored the right side, there
was a smaller epidural fluid collection full of pus. This was debrided and also irrigated
widely. The L4 nerve roots, the L5 nerve roots and the S1 nerve roots were all explored.
There was definitely pus tracking along the left S1 nerve root and this was debrided and pus
drained out also. At the end of the decompression, the field was irrigated again with
chlorhexidine solution followed by bacitracin and a normal saline solution using a total of
2 liters and then hemostasis was accomplished. Gelfoam was placed in the gutters laterally
and dorsally over the thecal sac. Two Hemovac drains were placed and brought out through
separate stab wound incisions inferior and lateral to the incision and then attached to bulb
suction. Following this, vancomycin powder was then rubbed into the edges of the tissue
also to help control infection. The incision was then closed in layers in usual fashion with
the skin being closed with subcuticular stitch. This was then covered with a Prineo
dressing which is a bacteriostatic mesh with glue to seal the incision. This was then
covered with Telfa, sterile 4 x 4's which were taped to the patient's back. The patient was
then maneuvered back into supine position on the PR cart where he underwent successful
reversal of general anesthesia and extubation in the operating room, moving both lower
extremities well at the end of the procedure and left the operating room in stable
condition.
 
Personally, I would only code 63267. To me it appears that the entire goal of all the laminectomies performed were strictly for the spinal abscess. 63267 would include debridement and includes multiple levels of laminectomies needed to clear out the abscess. (I have been coding neurosurgery for 4 years. I am a member of AANS, and do attend coding workshops hosted by AANS annually.)
 
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Can I please add you as a contact for future neurosurgery coding questions? I am here to help also if it is needed. :)
 
I would agree with only coding 63267. There isn’t any additional decompression to support 63047 at L4-L5, maybe 63005 but as is that would be difficult to support on an appeal.
 
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