lcole7465
Expert
The doctor performed the Vertiflex, CPT 22869/22870. However in the note it's documented that the 2nd level (CPT 22870) was aborted due to the patient becoming hypoxic. The first level was completed. Would I still bill CPT 22870 with modifier -53 since it was aborted. Or just bill for the 1st level?
Copy of note:
A fluoroscopic C-Arm was brought into AP orientation. The interspace between L2-3 was identified. The skin was anesthetized first with 1% lidocaine with epinephrine followed by 0.25% bupivacaine. A scalpel was used to make a stab incision down to the supraspinous ligament. A Vertiflex dilator was placed into the skin and advanced using intermittent fluoroscopic guidance in an alternating AP and lateral images down to the lamina between L2 and L3. A series of dilators were used to place the working cannula in proper position, dorsal to the lamina. A measuring gauge was introduced to the proper depth and the space was measured. The space measured and found to be 12mm. A 12mm Superion device was introduced and deployed at the correct depth and then advanced down to the lamina. AP and lateral images were taken to confirm proper placement of the device.
Attention was then focused on the L3-4 level. Attention was made to the leads that does not get caught at the entrance of the dilators. A scalpel was used to make a stab incision down to the supraspinous ligament. A Vertiflex dilator was placed into the skin and advanced using intermittent fluoroscopic guidance in an alternating AP and lateral images down to the lamina between L3 and L4.
At this point the patient became hypoxic and multiple attempts were done to open the airway without success. The anesthesiologist recommended to turn the patient on his lower back in the supine position to try to ventilate him better. Tegaderm was placed on the 2 incisions. Mask ventilation of the patient was successful in maintaining his airway. After stabilizing the patient by the anesthesiologist, the patient was turned on the left lateral down position and the incisions were irrigated and closed with 2-0 Vicryl sutures followed by monocril 3-0 and operative bandage was put in place. Pt taken to recovery in stable condition.
Thank you ...
Copy of note:
A fluoroscopic C-Arm was brought into AP orientation. The interspace between L2-3 was identified. The skin was anesthetized first with 1% lidocaine with epinephrine followed by 0.25% bupivacaine. A scalpel was used to make a stab incision down to the supraspinous ligament. A Vertiflex dilator was placed into the skin and advanced using intermittent fluoroscopic guidance in an alternating AP and lateral images down to the lamina between L2 and L3. A series of dilators were used to place the working cannula in proper position, dorsal to the lamina. A measuring gauge was introduced to the proper depth and the space was measured. The space measured and found to be 12mm. A 12mm Superion device was introduced and deployed at the correct depth and then advanced down to the lamina. AP and lateral images were taken to confirm proper placement of the device.
Attention was then focused on the L3-4 level. Attention was made to the leads that does not get caught at the entrance of the dilators. A scalpel was used to make a stab incision down to the supraspinous ligament. A Vertiflex dilator was placed into the skin and advanced using intermittent fluoroscopic guidance in an alternating AP and lateral images down to the lamina between L3 and L4.
At this point the patient became hypoxic and multiple attempts were done to open the airway without success. The anesthesiologist recommended to turn the patient on his lower back in the supine position to try to ventilate him better. Tegaderm was placed on the 2 incisions. Mask ventilation of the patient was successful in maintaining his airway. After stabilizing the patient by the anesthesiologist, the patient was turned on the left lateral down position and the incisions were irrigated and closed with 2-0 Vicryl sutures followed by monocril 3-0 and operative bandage was put in place. Pt taken to recovery in stable condition.
Thank you ...