Procedure:
Anterior spinal exposure for thoracic spine procedure.
Postoperative Diagnosis:
Spinal cord compression by bulging disc T6-T7.
Description of Procedure:
The left chest was prepped and draped in the usual sterile fashion. A posterolateral serratus-sparing thoracotomy was created in the 6th intercostal space, Upon entering the pleural space, there was no evidence of pleural disease or effusion. A pleural flap was created starting over the rib heads of the sixth and seventh rib, elevating the pleura from lateral to medial off of the vertebral bodies. Once his had been completely reflected medially, the sixth and seventh vertebral bodies were easily identified. The segmental vessels crossing the vertebral bodies were identified, ligated with clips and divided to provide full exposure.
___ was present and using flouroscopic guidance, was able to confirm the correct disc level had been exposesd and marked. In order to provide adequate access, the head of the rib at this space was removed using bone shears to debride the head of the rib from tissue articulation, This provided adequate exposure for the performance of neurosurgical disectomy and fusion. This was performed by Dr. ___ and will be dictated seperately by him.
At the completion of the neurosurgical procedure, the entire area was carefully inspected for hemostasis. The pleural flap was then closed over the hardware. A single 28 French straight chest tube was placed through a separate stab incision posteriorly to the apex. The ribs were reapproximated using two figure of eight 2-0 Dexon sutures. These sutures were passed through holes drilled in the lower rib and around the upper rib to avoid compression of the neurovascular bundle and minimize post thoracotomy pain. The serratus was then tacked back into place with 0 Vicryl. The lattisumus muscle was closed using 2-0 Dexon. Skin and subcutaneous tissue were then irrigated and closed in two layers using 2-0 and 3-0 Vicryl for subcutaneous and subcuticular suture. The patient tolerated procedure well, was extubated in the OR and taken to the post anesthesia care unit in stable condition.
The diagnosis code I have: 722.11
The surgical procedure procedure I am at a loss. At first I thought 32095 but their is no biopsy done here. Then I looked at 22212, and I am leaning toward this one. I would append modifier 62 since there are two surgeons performing together as primary surgeons.
Thanks for your help!
Anterior spinal exposure for thoracic spine procedure.
Postoperative Diagnosis:
Spinal cord compression by bulging disc T6-T7.
Description of Procedure:
The left chest was prepped and draped in the usual sterile fashion. A posterolateral serratus-sparing thoracotomy was created in the 6th intercostal space, Upon entering the pleural space, there was no evidence of pleural disease or effusion. A pleural flap was created starting over the rib heads of the sixth and seventh rib, elevating the pleura from lateral to medial off of the vertebral bodies. Once his had been completely reflected medially, the sixth and seventh vertebral bodies were easily identified. The segmental vessels crossing the vertebral bodies were identified, ligated with clips and divided to provide full exposure.
___ was present and using flouroscopic guidance, was able to confirm the correct disc level had been exposesd and marked. In order to provide adequate access, the head of the rib at this space was removed using bone shears to debride the head of the rib from tissue articulation, This provided adequate exposure for the performance of neurosurgical disectomy and fusion. This was performed by Dr. ___ and will be dictated seperately by him.
At the completion of the neurosurgical procedure, the entire area was carefully inspected for hemostasis. The pleural flap was then closed over the hardware. A single 28 French straight chest tube was placed through a separate stab incision posteriorly to the apex. The ribs were reapproximated using two figure of eight 2-0 Dexon sutures. These sutures were passed through holes drilled in the lower rib and around the upper rib to avoid compression of the neurovascular bundle and minimize post thoracotomy pain. The serratus was then tacked back into place with 0 Vicryl. The lattisumus muscle was closed using 2-0 Dexon. Skin and subcutaneous tissue were then irrigated and closed in two layers using 2-0 and 3-0 Vicryl for subcutaneous and subcuticular suture. The patient tolerated procedure well, was extubated in the OR and taken to the post anesthesia care unit in stable condition.
The diagnosis code I have: 722.11
The surgical procedure procedure I am at a loss. At first I thought 32095 but their is no biopsy done here. Then I looked at 22212, and I am leaning toward this one. I would append modifier 62 since there are two surgeons performing together as primary surgeons.
Thanks for your help!