Alif l5-s1

nlbarnes

Guru
Messages
188
Location
Escondido, CA
Best answers
0
Doctor has 22558, 22853, 22612, 22840

Shouldn't 22840 be 22845 and any other corrections?

POSTOPERATIVE DIAGNOSES:
1. Isthmic spondylolisthesis, L5-S1.
2. Bilateral pars defects chronic L5.
3. Foraminal stenosis, bilateral L5-S1.

PROCEDURES:
1. Anterior lumbar interbody fusion with placement of interbody
fusion device and buttress plate fixation, L5-S1.
2. Posterior spinal fusion with instrumentation, L5-S1.

IMPLANTS:
SeaSpine a-POD PEEK/ titanium interbody fusion device L5-S1 and
SeaSpine spin plate titanium buttress plate fixation, L5-S1.
Posterior instrumentation was Medtronic Legacy titanium pedicle screw
system, L5-S1.

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, placed in a supine
position on the gurney, where general anesthesia obtained. The
patient was then carefully transitioned to the operating table to
allow for anterior approach to the lumbar spine. All pressure points
were appropriately padded. Abdomen was then prepped and draped in
normal sterile fashion. Surgical time-out completed. Appropriate
operative level was confirmed with intraoperative fluoroscopy. Once
appropriate levels identified, Dr. D then performed an
anterior exposure of the lumbar spine at L5-S1 and this will be
dictated under separate operative note. Once Dr. D provided
exposure, annulotomy was created at L5-S1 after appropriate
confirmation of visualization on x-ray of the appropriate operative
level. Annulotomy was created anteriorly. Serial curettage of the
disk space was then performed. Appropriate size implant was then
selected to match patient anatomy, and with the placement of the
anterior interbody device, there was excellent interference fit of the
implant as well as reduction of the spondylolisthesis approximately
50% which was simply the anterior based interbody procedure alone.
The appropriate size implant was selected, appropriate position within
the intervertebral space, and then buttress plate fixation was engaged
spanning the intervertebral space creating fixation at L5 and S1
respectively at the point of implant fixation. With stable anterior
end plate fixation completed, the anterior component of the procedure
was completed. Final fluoroscopic imaging showed excellent position
of the implant on both AP and lateral fluoroscopic imaging and all
sponges and instrumentation removed from the abdomen. The wound was
then closed in layers and sterile dressing was placed. The patient
was then carefully rolled to the prone position on Jackson table with
all pressure points appropriately padded. Back was then prepped and
draped in normal sterile fashion. Surgical time-out was completed.
Two paramedian incisions were made over the starting points of the L5
and S1 pedicles respectively. Skin and subcutaneous tissues dissected
sharply. The investing fascia of the posterior spinal muscle was then
divided longitudinally using Bovie electrocautery. Blunt dissection
of the posterior spinal musculature was then performed. Using Bovie
electrocautery, the sacral ala of S1 was exposed bilaterally. The
transverse process of L5 were exposed bilaterally. These were
decorticated using a high-speed burr and then the decorticated bone
was mixed with some additional beta-tricalcium phosphate and then this
graft material was packed densely over the exposed decorticated bony
elements from L5-S1 respectively. Cannulated needles were then
utilized to cannulate the pedicles of L5 and S1 respectively with care
taken to maintain the needle tips lateral to the medial pedicle wall
during the traverse of the pedicles bilaterally. Guidewires were then
placed through the pedicle into the vertebral bodies bilaterally with
excellent wire position confirmed with AP and lateral fluoroscopic
imaging. The pedicle channels were then carefully tapped.
Appropriate-sized screws were then selected to match patient anatomy,
seated over the guidewires through the pedicles and the vertebral
bodies bilaterally with excellent screw purchase achieved at all 4
screw points. The connecting rods for the system were then placed
within the multiaxial heads of the system and with final tightening,
there was some additional reduction of the spondylolisthesis was well
as restoration of lordosis using the lordosis created on the Jackson
table to maximize lordotic position at L5-S1. Final tightening of the
 

mhstrauss

True Blue
Messages
1,240
Location
Baton Rouge
Best answers
0
Doctor has 22558, 22853, 22612, 22840

Shouldn't 22840 be 22845 and any other corrections?

POSTOPERATIVE DIAGNOSES:
1. Isthmic spondylolisthesis, L5-S1.
2. Bilateral pars defects chronic L5.
3. Foraminal stenosis, bilateral L5-S1.

PROCEDURES:
1. Anterior lumbar interbody fusion with placement of interbody
fusion device and buttress plate fixation, L5-S1.
2. Posterior spinal fusion with instrumentation, L5-S1.

IMPLANTS:
SeaSpine a-POD PEEK/ titanium interbody fusion device L5-S1 and
SeaSpine spin plate titanium buttress plate fixation, L5-S1.
Posterior instrumentation was Medtronic Legacy titanium pedicle screw
system, L5-S1.

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room, placed in a supine
position on the gurney, where general anesthesia obtained. The
patient was then carefully transitioned to the operating table to
allow for anterior approach to the lumbar spine. All pressure points
were appropriately padded. Abdomen was then prepped and draped in
normal sterile fashion. Surgical time-out completed. Appropriate
operative level was confirmed with intraoperative fluoroscopy. Once
appropriate levels identified, Dr. D then performed an
anterior exposure of the lumbar spine at L5-S1 and this will be
dictated under separate operative note. Once Dr. D provided
exposure, annulotomy was created at L5-S1 after appropriate
confirmation of visualization on x-ray of the appropriate operative
level. Annulotomy was created anteriorly. Serial curettage of the
disk space was then performed. Appropriate size implant was then
selected to match patient anatomy, and with the placement of the
anterior interbody device, there was excellent interference fit of the
implant as well as reduction of the spondylolisthesis approximately
50% which was simply the anterior based interbody procedure alone.
The appropriate size implant was selected, appropriate position within
the intervertebral space, and then buttress plate fixation was engaged
spanning the intervertebral space creating fixation at L5 and S1
respectively at the point of implant fixation. With stable anterior
end plate fixation completed, the anterior component of the procedure
was completed. Final fluoroscopic imaging showed excellent position
of the implant on both AP and lateral fluoroscopic imaging and all
sponges and instrumentation removed from the abdomen. The wound was
then closed in layers and sterile dressing was placed. The patient
was then carefully rolled to the prone position on Jackson table with
all pressure points appropriately padded. Back was then prepped and
draped in normal sterile fashion. Surgical time-out was completed.
Two paramedian incisions were made over the starting points of the L5
and S1 pedicles respectively. Skin and subcutaneous tissues dissected
sharply. The investing fascia of the posterior spinal muscle was then
divided longitudinally using Bovie electrocautery. Blunt dissection
of the posterior spinal musculature was then performed. Using Bovie
electrocautery, the sacral ala of S1 was exposed bilaterally. The
transverse process of L5 were exposed bilaterally. These were
decorticated using a high-speed burr and then the decorticated bone
was mixed with some additional beta-tricalcium phosphate and then this
graft material was packed densely over the exposed decorticated bony
elements from L5-S1 respectively. Cannulated needles were then
utilized to cannulate the pedicles of L5 and S1 respectively with care
taken to maintain the needle tips lateral to the medial pedicle wall
during the traverse of the pedicles bilaterally. Guidewires were then
placed through the pedicle into the vertebral bodies bilaterally with
excellent wire position confirmed with AP and lateral fluoroscopic
imaging. The pedicle channels were then carefully tapped.
Appropriate-sized screws were then selected to match patient anatomy,
seated over the guidewires through the pedicles and the vertebral
bodies bilaterally with excellent screw purchase achieved at all 4
screw points. The connecting rods for the system were then placed
within the multiaxial heads of the system and with final tightening,
there was some additional reduction of the spondylolisthesis was well
as restoration of lordosis using the lordosis created on the Jackson
table to maximize lordotic position at L5-S1. Final tightening of the



My thoughts are:

22558 for ALIF
22859 for cage--I don't see graft material documented with anterior approach to complete the interbody arthrodesis
22612 for posterior fusion
22840 for posterior nonsegmental instrumentation
20930 for allograft
20936 for autograft

For the buttress plate mentioned, I would get clarification from the surgeon on whether or not that is truly a separate plate. The buttress plates my docs use are typically part of the cage, just to secure the cage to the vertebra above and below, which does not justify billing 22845. If he DID use a separate plate for independent stabilization, then add 22845 also. And of course, add appropriate co-sx and multiple procedure modifiers.

HTH!
 

nlbarnes

Guru
Messages
188
Location
Escondido, CA
Best answers
0
Alif

Hi Meagan - here is the ALIF portion from the vascular surgeon. The first report was the ortho's I'm sure you realized. Thanks!

DESCRIPTION OF PROCEDURE:
This was taken down through the subcutaneous tissue to expose the anterior rectus sheath. The
anterior rectus sheath was divided to expose the rectus muscle. The
rectus muscle was retracted medially to expose the posterior sheath.
The posterior sheath was divided into the retroperitoneal space. The
retroperitoneal space was developed to expose the psoas muscle and the
iliac vessels. At that point, the abdominal contents and the ureter
were retracted medially. We dissected medial to the iliac vessels and
they were retracted laterally. The broad expanse of L5-S1 was
exposed. The sacral vessels were ligated and divided. We confirmed
disk space with fluoroscopic landmarks.

Dr. B then entered for diskectomy and placement of
intervertebral biomechanical device. This required the use of
multiple trial prostheses requiring removal and replacement of the
retractors on multiple occasions. With the final prosthesis in place,
anterior fixation was provided using spin plate fixation, this was to
prevent anterior extrusion. We then assured hemostasis. We removed
all sponges, retractors, and performed final imaging. With final
imaging found to be satisfactory, we allowed the abdominal contents to
fall back in place and closed. We closed the posterior sheath using 0
Vicryl in running fashion. We closed the anterior sheath using 0
 

mhstrauss

True Blue
Messages
1,240
Location
Baton Rouge
Best answers
0
Hi Meagan - here is the ALIF portion from the vascular surgeon. The first report was the ortho's I'm sure you realized. Thanks!

DESCRIPTION OF PROCEDURE:
This was taken down through the subcutaneous tissue to expose the anterior rectus sheath. The
anterior rectus sheath was divided to expose the rectus muscle. The
rectus muscle was retracted medially to expose the posterior sheath.
The posterior sheath was divided into the retroperitoneal space. The
retroperitoneal space was developed to expose the psoas muscle and the
iliac vessels. At that point, the abdominal contents and the ureter
were retracted medially. We dissected medial to the iliac vessels and
they were retracted laterally. The broad expanse of L5-S1 was
exposed. The sacral vessels were ligated and divided. We confirmed
disk space with fluoroscopic landmarks.

Dr. B then entered for diskectomy and placement of
intervertebral biomechanical device. This required the use of
multiple trial prostheses requiring removal and replacement of the
retractors on multiple occasions. With the final prosthesis in place,
anterior fixation was provided using spin plate fixation, this was to
prevent anterior extrusion. We then assured hemostasis. We removed
all sponges, retractors, and performed final imaging. With final
imaging found to be satisfactory, we allowed the abdominal contents to
fall back in place and closed. We closed the posterior sheath using 0
Vicryl in running fashion. We closed the anterior sheath using 0



Is this to clarify whether or not separate plate was used? Based on the statement "this was to prevent anterior extrusion", I would not bill a separate plate.
 
Top