Orthopedic Coding Alert

Question: For a child with congenital scoliosis, our surgeon performed growth rod revision and reinsertion of spinal fixators. Arthrodesis or fusion was not done. This is planned every six months as the child grows. The operative note reads as follows:

"An incision was made over the distal 4 screws. This was carried through skin and subcutaneous. The fascia was incised laterally over each of the set of 2 screws. All four set screws were removed. Another approximately 5 cm incision was made over the couplers. This was carried through skin and subcutaneous. Again, separate lateral  fascial incisions were made over the couplers themselves. The set screws were removed. The rods were then removed from each lower end of the construct. A right rod was placed followed by the left rod. These were locked into place on the coupler and we distracted right and then left at the bottom of the construct off the end of the rods. The wounds were irrigated out. They were all closed with a deep fascial stitch followed by a subcutaneous stitch and subcuticular skin stitch and Steri-Strips. The patient was awakened in the operating room with a normal neurologic exam and was taken to the recovery room in stable condition."

Arizona Subscriber

Answer: You report 22849 (Reinsertion of spinal fixation device) as it covers the removal and replacement of instrumentation.