Neurosurgery Coding Alert

Question: Our surgeon recorded the following procedures.Preoperative diagnoses:C2 arthritic pannus.Cervical cord injury.Cervical myelopathy.Postoperative diagnoses: C2 arthritic pannus. Cervical cord injury. Cervical myelopathy.Procedure performed:Occipital skull decompression.C1 laminectomy complete.Partial C2 laminectomy.Placement of an occipital cervical plate.Placement of lateral mass screws C2, C3 and C4 bilaterally.Placement of intralaminar posterolateral bone graft, Vitoss BM.Biopsy of posterior C2 ring.Description of procedure: "The patient was pinned in the Mayfield head holder and with six assistants we carefully turned the patient onto the gel rolls, being sure to maintain neutral alignment. Her C-collar was removed at this point in time. C-arm fluoroscopy was brought into the field to identify the occiput down to the level C4 on lateral imaging which was easily visible. The patient was then prepped and draped in the typical sterile fashion. A midline incision was made from the occipital protuberance down to about the level of C5. This incision was carried down to [...]