Need help figuring out a CPT code for the following procedure please.
Diagnosis: Bertolotti's syndrome Q76.49
Procedure: Bertolotti's decompression and takedown
Patient was placed prone. Small 3 cm incision was made over the SI joint and sacral ala, carried down through the fascia amd them using a muscle splitting technique was utilized to identify the sacral ala and junction of the transverse process. The Bertolotti's malformation wrapped significantly around the ventral side of her sacral ala and I was concerned that I would have to take a significant amount of sacral ala down to completely remove the pseudoarticulation; however, was able to identify the medial and lateral borders of the L5 transverse process and using a bur and Kerrisons, take this down with about a centimeters width. I was able to identify transverse process and sacral ala and move them independently, identifying that there were no connections then remaining. I bone waxed the exposed cancellous bone to ensure no recurrence. Turned my attention to hemostasis. I closed the fascia with # 1 vicryl, skin with 2-0 vicryl and 4-0 monocryl.
Diagnosis: Bertolotti's syndrome Q76.49
Procedure: Bertolotti's decompression and takedown
Patient was placed prone. Small 3 cm incision was made over the SI joint and sacral ala, carried down through the fascia amd them using a muscle splitting technique was utilized to identify the sacral ala and junction of the transverse process. The Bertolotti's malformation wrapped significantly around the ventral side of her sacral ala and I was concerned that I would have to take a significant amount of sacral ala down to completely remove the pseudoarticulation; however, was able to identify the medial and lateral borders of the L5 transverse process and using a bur and Kerrisons, take this down with about a centimeters width. I was able to identify transverse process and sacral ala and move them independently, identifying that there were no connections then remaining. I bone waxed the exposed cancellous bone to ensure no recurrence. Turned my attention to hemostasis. I closed the fascia with # 1 vicryl, skin with 2-0 vicryl and 4-0 monocryl.