kpugoul
New
I have a provider who performs an ACDF and a posterior/posterolateral cervical fusion on the same day. However, his report for the posterior procedure reads like a 0219T but is listed on the report as a posterior cervical fusion (22600). I'm hoping someone can take a look and provide feedback.
Here is the narrative of the posterior procedure:
The patient was positioned prone. Eyes were protected. Neck was placed in neutral alignment. Ulnar and peroneal nerves were protected. The patient was secured to the operating room table. Neck was sterilely scrubbed and draped in the usual fashion using Ioban skin sealant. True AP and lateral fluoroscopic images were obtained. Skin, subcutaneous tissue, muscle were infiltrated with local anesthetic. Incision was made, carried down through skin, subcutaneous tissue onto fascia. Blunt dissection was carried out to the C3-C4 facet joint on the left and right. A chisel was inserted into the facet joint at C3-C4. Care was taken to avoid neurovascular injury. Tubular retractor was placed, docked on the lateral mass of C3 and C4. Lateral mass of C3 and C4 were directly decorticated with a decorticating tool. Facet joint was prepared with the rasps. Additional coring reamer was utilized to prepare the facet joint and lateral mass. A titanium implant and cage was packed with OssDsign synthetic allograft and impacted into the facet joint. Screws were placed cranially and caudally into the lateral mass creating a fixed construct. Additional synthetic allograft was placed directly over the decorticated lateral mass of C3 and C4, allowing for posterolateral fusion. The procedure was repeated on the right side. Retractors were removed and the would was closed in layers. Sterile dressing was applied. sponge, needle and instrument counts reported as correct. No known intraoperative complications. SSEP free running EMG, and MEP remained at baseline.
My provider is listing this procedure as C3-C4 posterior cervical fusion, posterior instrumentation, insertion of biomechanical device and allograft. I disagree but would like to hear what the experts think.
Thanks in advance!
K
Here is the narrative of the posterior procedure:
The patient was positioned prone. Eyes were protected. Neck was placed in neutral alignment. Ulnar and peroneal nerves were protected. The patient was secured to the operating room table. Neck was sterilely scrubbed and draped in the usual fashion using Ioban skin sealant. True AP and lateral fluoroscopic images were obtained. Skin, subcutaneous tissue, muscle were infiltrated with local anesthetic. Incision was made, carried down through skin, subcutaneous tissue onto fascia. Blunt dissection was carried out to the C3-C4 facet joint on the left and right. A chisel was inserted into the facet joint at C3-C4. Care was taken to avoid neurovascular injury. Tubular retractor was placed, docked on the lateral mass of C3 and C4. Lateral mass of C3 and C4 were directly decorticated with a decorticating tool. Facet joint was prepared with the rasps. Additional coring reamer was utilized to prepare the facet joint and lateral mass. A titanium implant and cage was packed with OssDsign synthetic allograft and impacted into the facet joint. Screws were placed cranially and caudally into the lateral mass creating a fixed construct. Additional synthetic allograft was placed directly over the decorticated lateral mass of C3 and C4, allowing for posterolateral fusion. The procedure was repeated on the right side. Retractors were removed and the would was closed in layers. Sterile dressing was applied. sponge, needle and instrument counts reported as correct. No known intraoperative complications. SSEP free running EMG, and MEP remained at baseline.
My provider is listing this procedure as C3-C4 posterior cervical fusion, posterior instrumentation, insertion of biomechanical device and allograft. I disagree but would like to hear what the experts think.
Thanks in advance!
K
