lindaconway
Networker
Operative report as follows:
58 y.o. female with acute onset of right UE and then right LE weakness associated with physical activity and recent chiropractic adjustments. Patient has acute epidural hematoma posterior to her spinal cord from C3-C6. She has been developing progressive weakness and sensory loss to her extremities over the past one day.
IMAGING: MRI C-spine shows acute epidural hematoma posterior to the spinal cord from C2-C7.
Pre-op and Post-op dx: Acute C2-C7 cervical posterior epidural hematoma with spinal cord compression.
Procedure performed: 1. Complete laminectomy of C3-C7. 2. Partial laminectomy of C23. Evacuation of posterior cervical epidural hematoma. 4. Bilateral foraminotomies C3-C7
Description of procedure:
...patient was placed in a mayfield head holder, and then rolled carefully prone on to a Jackson table and padded appropriately, the head secured to the fram carefully in neutral position..... The planned C2-C7 incision was marked, etc...
dissection was carried down to expose the spinous processes of C2-C7, as well as their lamina. The dissection was carried out to expose the full length of the lamina but stopped short of exposing the lateral masses.
A laminectomy was then carried out from C3 to C7 using the high speed drill and a 3 mm cutting burr- by means of making troughs along the lateral edge of the lamina on both sides, also used were curettes and kerrison rongeurs. The lamina were carefully removed en bloc. The dura was found to have a congealed hemorrhage over it, with spinal cord compression. C2 was partially laminectomized using kerrisons to expose the superior extent of the hemorrhage. Throught the case copious irrigation was used. The foramina were then inspected and widened bilaterally using kerrisons from C3-C7 and any epidural blood found tracking into the foramen was removed. After circumferential inspection of the spinal cord to remove all traces of the epidural hematoma, meticulous hemostatsi was achieved.
Draines, suture, dressing etc.
If you've made it this far, thank you. This was coded as follows, which passes edits:
63045, 1 unit
63048, 4 units
63265-59, 1 unit
Initially all procedures were allowed, but under the non-network fee schedule as we are out of network. The patient asked that it be sent back for reprocessing since no network providers are available in our area. When it was reprocessed lines 2 and 3 were paid in full, but line 1 was excluded for medical necessity. The more I look at the coding the more I am questioning it. Before I write the Second Level Appeal letter I'd like to see if I can get any input from coders with more experience.
Thank you for any help you might be able to offer.
58 y.o. female with acute onset of right UE and then right LE weakness associated with physical activity and recent chiropractic adjustments. Patient has acute epidural hematoma posterior to her spinal cord from C3-C6. She has been developing progressive weakness and sensory loss to her extremities over the past one day.
IMAGING: MRI C-spine shows acute epidural hematoma posterior to the spinal cord from C2-C7.
Pre-op and Post-op dx: Acute C2-C7 cervical posterior epidural hematoma with spinal cord compression.
Procedure performed: 1. Complete laminectomy of C3-C7. 2. Partial laminectomy of C23. Evacuation of posterior cervical epidural hematoma. 4. Bilateral foraminotomies C3-C7
Description of procedure:
...patient was placed in a mayfield head holder, and then rolled carefully prone on to a Jackson table and padded appropriately, the head secured to the fram carefully in neutral position..... The planned C2-C7 incision was marked, etc...
dissection was carried down to expose the spinous processes of C2-C7, as well as their lamina. The dissection was carried out to expose the full length of the lamina but stopped short of exposing the lateral masses.
A laminectomy was then carried out from C3 to C7 using the high speed drill and a 3 mm cutting burr- by means of making troughs along the lateral edge of the lamina on both sides, also used were curettes and kerrison rongeurs. The lamina were carefully removed en bloc. The dura was found to have a congealed hemorrhage over it, with spinal cord compression. C2 was partially laminectomized using kerrisons to expose the superior extent of the hemorrhage. Throught the case copious irrigation was used. The foramina were then inspected and widened bilaterally using kerrisons from C3-C7 and any epidural blood found tracking into the foramen was removed. After circumferential inspection of the spinal cord to remove all traces of the epidural hematoma, meticulous hemostatsi was achieved.
Draines, suture, dressing etc.
If you've made it this far, thank you. This was coded as follows, which passes edits:
63045, 1 unit
63048, 4 units
63265-59, 1 unit
Initially all procedures were allowed, but under the non-network fee schedule as we are out of network. The patient asked that it be sent back for reprocessing since no network providers are available in our area. When it was reprocessed lines 2 and 3 were paid in full, but line 1 was excluded for medical necessity. The more I look at the coding the more I am questioning it. Before I write the Second Level Appeal letter I'd like to see if I can get any input from coders with more experience.
Thank you for any help you might be able to offer.