63267

jandrada

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Would like to get some help as to how to code for laminotomy. Here are the chart notes.
PREOPERATIVE DIAGNOSIS:
1. Lumbar Stenosis at L 2/3 due to facet cyst and ligamentum flavum hypertrophy with neurogenic claudication
2. Lumbar Stenosis at L 3/4 due to facet cyst and ligamentum flavum hypertrophy with neurogenic claudication
3. lumbar radiculopathy

POSTOPERATIVE DIAGNOSIS:
Same

OPERATION:
1. bilateral L 2/3 laminotomy, medial facetectomy and foraminotomy for extradural cyst resection
2. bilateral L 3/4 laminotomy, medial facetectomy and foraminotomy for extradural cyst resection
3. Use of operative microscope
4. Interpretation of intraoperative fluoroscopy.

BRIEF INDICATION FOR PROCEDURE:
The patient presents today to discuss upcoming L2-3 and L3-4 laminectomy procedure for lumbar stenosis with symptoms of neurogenic claudication. The patient was originally offered laminectomy on 6/29/2015 but was unable to proceed at that time because of a cardiac stenting procedure 4/2015 and 6 month post-op plavix requirement. He was diagnosed with acute and subacute pulmonary emboli in November 2015 and was started on xarelto. He is followed by Pulmonologist Dr. x . He had a temporary IVC filter placed 2/2016 to allow him to stop xarelto for 1 week prior to surgery and to allow him to have an endoscopy procedure for work up of iron deficiency anemia. The patient had a corneal transplant in the left eye in October 2015. He has been having problems with the transplant but assures me that his ophthalmologist is aware of his upcoming surgery that will involve prone positioning and has cleared him to proceed.

The patient wishes to proceed with L2-3 and L3-4 minimally invasive bilateral laminectomies for symptoms of neurogenic claudication. We have discussed the goals of surgery which are to stop progression of his neurogenic claudication symptoms with the hope of improving his walking distance and bilateral foot and leg numbness. We have discussed the risks of surgery including bleeding, infection, CSF leak and the risks associated with general anesthesia including MI, CVA and death. The patient has reviewed and signed the consent form and pre-operative instructions were reviewed. The patient had an IVC filter placed 2/2016 in preparation for surgery and will stop xarelto for 5 days prior to surgery and 2 days post-op. Given his complex medical history, I think it would be helpful for patient to be seen in the surgical pre-admission unit for pre-surgical evaluation to further evaluate this complex patient and ensure that it is safe to proceed from a general anesthesia standpoint. The patient is in agreement with this plan and all of his questions were answered to his apparent satisfaction today.

BRIEF DESCRIPTION OF PROCEDURE:
After consent was obtained from the patient, they were brought to the operative theater and intubated by anesthesia. They were then placed prone onto a Jackson table with a Wilson frame. The Wilson frame was then cranked up to increase the disk space height. We then prepped and draped the patient in the usual fashion. A spinal needle prior to this was used to localize our level. We then did a preoperative time-out per hospital policy. Once everyone was in agreement, we proceeded.

After the time-out, we infiltrated the skin and down to the lamina with 10 mL of 0.25 percent Marcaine with epinephrine. We then sharply incised the preplanned incision site using a #10 blade. This was carried down to the lumbodorsal fascia, which was then opened sharply using the cutting setting on the Bovie cautery. A Metrx dilator system was used to do a muscle splitting dissection down to the lamina. We then placed a 18mmx6cm Metrx tubular retractor to expose the LEFT L2/3 interlaminar space. Fluoroscopy was used to confirm the correct level.

A high-speed drill was used to then perform a local laminectomy and medial facetectomy to access this region. After this was done, 1 and 2 mm Kerrison punches were used to complete the laminectomy and foraminotomy and decompress the dura. There was a very large extradural cyst at this level with 2 lobes which was removed piecemeal. This was the main constricting factor along with the ligamentous hypertrophy does resulting in his severe spinal stenosis at this level. Once we had a good lateral exposure, we used a blunt nerve hook to confirm that we had removed the ligamentum flavum in this region. The dura was lax without significant compression at this point.

The Metrx dilator system was then angled to face the base of the spinous process and contralateral lamina on the RIGHT side. A high-speed drill was used to then perform a local laminectomy and medial facetectomy to access this region. After this was done, 1 and 2 mm Kerrison punches were used to complete the laminectomy and foraminotomy and decompress the dura including removal of the right-sided portion of this large facet cyst. Once we had a good lateral exposure, we used a blunt nerve hook to confirm that we had removed the ligamentum flavum in this region. The dura was lax without significant compression at this point.

Once we were happy with our decompression, we thoroughly irrigated out the space with bacitracin infused saline and used powdered gelfoam and thrombin for hemostasis. There were no loose fragments of bone or tissue noted. The dura seemed much more lax upon return back to its original position.

We closed the deep lumbodorsal fascia at this level using a 0 Vicryl. The dilator system was then removed and thorough irrigation was done of the incision site.

A 2nd operative site was then marked out at the L3/4 level , and we infiltrated the skin and down to the lamina with 10 mL of 0.25 percent Marcaine with epinephrine. We then sharply incised the preplanned incision site using a #10 blade. This was carried down to the lumbodorsal fascia, which was then opened sharply using the cutting setting on the Bovie cautery. A Metrx dilator system was used to do a muscle splitting dissection down to the lamina. We then placed a 18mmx6cm Metrx tubular retractor to expose the LEFT L3/4 interlaminar space. Fluoroscopy was used to confirm the correct level.

A high-speed drill was used to then perform a local laminectomy and medial facetectomy to access this region. After this was done, 1 and 2 mm Kerrison punches were used to complete the laminectomy and foraminotomy and decompress the dura. There was once again a very large extradural cyst at this levelwhich was removed piecemeal. This was the main constricting factor resulting in his severe spinal stenosis at this level. Once we had a good lateral exposure, we used a blunt nerve hook to confirm that we had removed the ligamentum flavum in this region. The dura was lax without significant compression at this point.

The Metrx dilator system was then angled to face the base of the spinous process and contralateral lamina on the RIGHT side. A high-speed drill was used to then perform a local laminectomy and medial facetectomy to access this region. After this was done, 1 and 2 mm Kerrison punches were used to complete the laminectomy and foraminotomy and decompress the dura including removal of the right-sided portion of this large facet cyst.

We then began closure. We closed the deep lumbodorsal fascia using a 0-Vicryl. This was done in an interrupted fashion. The superficial fascia was closed on both sides using a 3-0 Vicryl in an interrrupted fashion. The skin was closed using a 3-0 Caprosyn/Monocryl in a subcuticular fashion. Dermabond was placed on the skin. We then infiltrated an additional 10 mL circumferentially around the incision


Is it correct to bill 2 63267's in 2 separate lines and one is appended a modifier 76. MUE is 1.

Your help will be greatly appreciated.
 

avon4117

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63267 only allows 1 mue per day so you can only bill the single code. Also bill for the scope 69990
 
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