knderouselle
New
Posted in Orthopaedics also....
We need help or guidance coding the below op-note. There are 3 different coding scenarios at the bottom for review. Any help or links woul dbe greatly appreciated.
PREOPERATIVE DIAGNOSIS: Adjacent level disease at L3-4 with severe stenosis.
POSTOPERATIVE DIAGNOSIS: Adjacent level disease at L3-4 with severe
stenosis.
PROCEDURES
1. We did L3 laminectomy, L3-4 decompression and resection of synovial cyst.
2. Bilateral facetectomies and foraminotomies.
3. Also decompression of the thecal sac.
4. Posterior diskectomy at L3-4.
5. Placement of posterior interbody arthrodesis at L3-4.
6. Placement of biomechanical device 12-mm lordotic PEEK cage packed with
autograft bone calcium phosphate posterior instrumentation from L3 through
L5.
7. Removal of old drives at L4-5.
8. Exploration of fusion at L4-5.
9. Re-insertion of rods from L3 to L5.
10. Posterolateral arthrodesis at L3-4.
11. Use of fluoroscopy.
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 100 mL.
DRAINS: Placement of JP drain.
INDICATIONS FOR SURGERY: Mr.----- is a pleasant 68-year-old male who is
well known to me and is status post L4-5 TLIF several months ago. However,
the patient started developing adjacent-level disease with severe stenosis
and synovial cyst formation. The surgery was offered to him to him to entail
the above procedures. The surgery was discussed with him. Risks included
infection, bleeding, CSF leak, need for additional surgery. Despite that,
the patient agreed to surgery and wished to proceed.
PROCEDURE: The patient was brought to the operating room. After general
anesthesia was induced, he was placed on the operating table in the prone
position. All body contacts with the table were appropriately padded. He
was then prepped and draped in a surgical standard fashion. A time-out was
taken. Then a midline incision was performed over the old incision. The
muscles and fascia were taken out to expose the posterolateral elements. An
x-ray was taken to confirm our level. Then a laminectomy at L3-4 was
performed. We encountered large facets, large hypertrophied ligamentum
flavum. These were all removed to decompress the thecal sac.
Once this was done, then we placed pedicle screws at L3-4 bilaterally. We
used 6.5 x 50s. Then, we removed the old drives from L4-5. Then we did a
diskectomy at L3-4, decorticated the interbody endplates preparing for
fusion. Then a 12-cm lordotic PEEK cage was placed under fluoroscopic
guidance after it was packed with autograft bone calcium phosphate. Once
this was done, copious irrigation was performed and hemostasis was obtained.
Then we brought in the rods that were cut to size and bent to shape, placing
the screw heads from L3 to L5 and anchored with setscrews. Once this was
done, then the posterolateral elements at L3-4 were decorticated and prepared
for fusion. Then, we placed autograft bone calcium phosphate for
posterolateral elements for fusion. A 7-flat JP drain was placed and 2 g of
vancomycin powder was inserted in the surgical bed to reduce surgical
infection. Once this was done, the muscles and fascia were closed using
0-Vicryl interrupted suture, subcutaneous fascia with 2-0 Vicryl suture, and
skin with staples.
1st coding: 22633,63047-59,22842,22851,63048-59
2nd coding: 22630,22851,22842
3rd coding: 22633,63030-59,22842,22851,63035-59
We need help or guidance coding the below op-note. There are 3 different coding scenarios at the bottom for review. Any help or links woul dbe greatly appreciated.
PREOPERATIVE DIAGNOSIS: Adjacent level disease at L3-4 with severe stenosis.
POSTOPERATIVE DIAGNOSIS: Adjacent level disease at L3-4 with severe
stenosis.
PROCEDURES
1. We did L3 laminectomy, L3-4 decompression and resection of synovial cyst.
2. Bilateral facetectomies and foraminotomies.
3. Also decompression of the thecal sac.
4. Posterior diskectomy at L3-4.
5. Placement of posterior interbody arthrodesis at L3-4.
6. Placement of biomechanical device 12-mm lordotic PEEK cage packed with
autograft bone calcium phosphate posterior instrumentation from L3 through
L5.
7. Removal of old drives at L4-5.
8. Exploration of fusion at L4-5.
9. Re-insertion of rods from L3 to L5.
10. Posterolateral arthrodesis at L3-4.
11. Use of fluoroscopy.
ANESTHESIA: General.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: 100 mL.
DRAINS: Placement of JP drain.
INDICATIONS FOR SURGERY: Mr.----- is a pleasant 68-year-old male who is
well known to me and is status post L4-5 TLIF several months ago. However,
the patient started developing adjacent-level disease with severe stenosis
and synovial cyst formation. The surgery was offered to him to him to entail
the above procedures. The surgery was discussed with him. Risks included
infection, bleeding, CSF leak, need for additional surgery. Despite that,
the patient agreed to surgery and wished to proceed.
PROCEDURE: The patient was brought to the operating room. After general
anesthesia was induced, he was placed on the operating table in the prone
position. All body contacts with the table were appropriately padded. He
was then prepped and draped in a surgical standard fashion. A time-out was
taken. Then a midline incision was performed over the old incision. The
muscles and fascia were taken out to expose the posterolateral elements. An
x-ray was taken to confirm our level. Then a laminectomy at L3-4 was
performed. We encountered large facets, large hypertrophied ligamentum
flavum. These were all removed to decompress the thecal sac.
Once this was done, then we placed pedicle screws at L3-4 bilaterally. We
used 6.5 x 50s. Then, we removed the old drives from L4-5. Then we did a
diskectomy at L3-4, decorticated the interbody endplates preparing for
fusion. Then a 12-cm lordotic PEEK cage was placed under fluoroscopic
guidance after it was packed with autograft bone calcium phosphate. Once
this was done, copious irrigation was performed and hemostasis was obtained.
Then we brought in the rods that were cut to size and bent to shape, placing
the screw heads from L3 to L5 and anchored with setscrews. Once this was
done, then the posterolateral elements at L3-4 were decorticated and prepared
for fusion. Then, we placed autograft bone calcium phosphate for
posterolateral elements for fusion. A 7-flat JP drain was placed and 2 g of
vancomycin powder was inserted in the surgical bed to reduce surgical
infection. Once this was done, the muscles and fascia were closed using
0-Vicryl interrupted suture, subcutaneous fascia with 2-0 Vicryl suture, and
skin with staples.
1st coding: 22633,63047-59,22842,22851,63048-59
2nd coding: 22630,22851,22842
3rd coding: 22633,63030-59,22842,22851,63035-59