Wiki Aborted cage placement

JenReyn99

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Here is the scrubbed op report. I don't see the exploration of fusion that is listed in procedure list. How would you code this?
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Here is the scrubbed op report. I don't see the exploration of fusion that is listed in procedure list. How would you code this?
View attachment 6146
View attachment 6147
This operative report is incomplete. first question. What is the diagnosis? Diagnosis drives Decompression. second question. Where is the previous fusion? I do not see any instrumentation adjusted or removed? third question. was this an extension of previous fusion or refusion? third question. Is this stereotactic navigation such as spine stealth? not enough to code navigation (where is the preplanning, name of system etc.). 4th question. is this non segmental or segmental instrumentation? I do not see any connectors placed but he placed screws 3 levels so that needs to be specified. 5th question. was the original plan interbody fusion? If so, it was not aborted, it changed from interbody to regular PSF. From this report, I can code Arthrodesis L5-S1 22612, allograft/DBM 20930. Not enough to code per the procedure listing.
 
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