Mjanko82
Contributor
I had an appeals pushed off to me for C1889. The hospital sent the medical records but no detail as to what they were tying to apply C1889 to. Several implants were used in this procedure. I do not code spinal and didn't see a spinal thread. Is anyone able to help me break down what C1889 might be billed for on this case:
PROCEDURE IN DETAIL: Colleen was identified and brought to the operating room. Anesthesia was initiated. She was
placed prone on an open Jackson table, padding all pressure points in the supine position. Her back was then prepped
and draped in a standard fashion. Time-out was performed, confirming patient, procedure, etc. Following this, a linear
incision was placed in the lower thoracic spine to allow us to fix the spinal frame for navigation. A spinous process clamp
was then affixed and we obtained O-arm spin. Following this, we used Stealth to plan trajectories for our percutaneous
left-sided pedicle screws. We performed a second time-out, confirming the L4 and L5 levels. Following this, we planned
our incision, anesthetized and carried it down, opened the thoracolumbar fascia sharply and used the following technique
to place our screws. A pilot hole was drilled with navigated drill. This was then under tapped with a navigated tap that
was 6.5 mm in diameter. We then navigated in 7.5 x 45 mm screws bilaterally on the left side only at L4-L5. We then
repeated the process on the right side without placing the screws and had virtual screw holes set for ultimate implantation
following completion of our interbody fusion. We repeated the planning process and tapping without placement of the
screws on the right side and stored this on the Stealth. We then used Stealth to navigate a Quadrant retractor into place
and parked this using the docking system. This was then fully deployed, and we dissected the muscle off the facet joint
under microscopic magnification and navigation. We then completed a complete facetectomy of the L4-L5 joint, removing
the entirety of the joint, the medial facet as well as the lateral portion of the lamina. This allowed us access the inner
foraminal space and allowed us to fully decompress this compressed neural foramen. We then used microsurgical
dissection to identify the nerve root. We then incised the anulus of the L4-L5 disk and used sequential endplate shavers
to prepare this for fusion. We got up to 10, and we performed a radical diskectomy with the sequential curettes and
pituitaries until we had fully decompressed the disk space. Following completion of preparation, we then implanted a
navigated 7 x 23 mm catalyft spacer into the disk space and fully deployed this. We then injected the injectable Grafton
as well as the BMA which had been done previously with the hip with a Jamshidi needle placed into the iliac crest and
spun down on the back table. This was then all injected for interbody fusion. We then copiously irrigated the wound,
made sure the neural foramen was adequately decompressed and removed the retractor from the field. We then
navigated 7.5 x 45 mm screws on the right side at L4 and L5, measured rods and friction tightened 40 mm rods into place.
These were capped rods. We then obtained O-arm navigational spin. We were satisfied with all our hardware, final
tightened everything in place, broke off the tabs, decorticated the lateral facets on the right side at L4-L5, and after
copiously irrigating the wound, placed remaining Grafton locally harvested autograft for posterolateral arthrodesis L4-L5.
We removed the spinous process clamp and closed all wounds, ending with glue. The patient tolerated the procedure
well with plan to extubate and transfer to recovery in stable condition.
PROCEDURE IN DETAIL: Colleen was identified and brought to the operating room. Anesthesia was initiated. She was
placed prone on an open Jackson table, padding all pressure points in the supine position. Her back was then prepped
and draped in a standard fashion. Time-out was performed, confirming patient, procedure, etc. Following this, a linear
incision was placed in the lower thoracic spine to allow us to fix the spinal frame for navigation. A spinous process clamp
was then affixed and we obtained O-arm spin. Following this, we used Stealth to plan trajectories for our percutaneous
left-sided pedicle screws. We performed a second time-out, confirming the L4 and L5 levels. Following this, we planned
our incision, anesthetized and carried it down, opened the thoracolumbar fascia sharply and used the following technique
to place our screws. A pilot hole was drilled with navigated drill. This was then under tapped with a navigated tap that
was 6.5 mm in diameter. We then navigated in 7.5 x 45 mm screws bilaterally on the left side only at L4-L5. We then
repeated the process on the right side without placing the screws and had virtual screw holes set for ultimate implantation
following completion of our interbody fusion. We repeated the planning process and tapping without placement of the
screws on the right side and stored this on the Stealth. We then used Stealth to navigate a Quadrant retractor into place
and parked this using the docking system. This was then fully deployed, and we dissected the muscle off the facet joint
under microscopic magnification and navigation. We then completed a complete facetectomy of the L4-L5 joint, removing
the entirety of the joint, the medial facet as well as the lateral portion of the lamina. This allowed us access the inner
foraminal space and allowed us to fully decompress this compressed neural foramen. We then used microsurgical
dissection to identify the nerve root. We then incised the anulus of the L4-L5 disk and used sequential endplate shavers
to prepare this for fusion. We got up to 10, and we performed a radical diskectomy with the sequential curettes and
pituitaries until we had fully decompressed the disk space. Following completion of preparation, we then implanted a
navigated 7 x 23 mm catalyft spacer into the disk space and fully deployed this. We then injected the injectable Grafton
as well as the BMA which had been done previously with the hip with a Jamshidi needle placed into the iliac crest and
spun down on the back table. This was then all injected for interbody fusion. We then copiously irrigated the wound,
made sure the neural foramen was adequately decompressed and removed the retractor from the field. We then
navigated 7.5 x 45 mm screws on the right side at L4 and L5, measured rods and friction tightened 40 mm rods into place.
These were capped rods. We then obtained O-arm navigational spin. We were satisfied with all our hardware, final
tightened everything in place, broke off the tabs, decorticated the lateral facets on the right side at L4-L5, and after
copiously irrigating the wound, placed remaining Grafton locally harvested autograft for posterolateral arthrodesis L4-L5.
We removed the spinous process clamp and closed all wounds, ending with glue. The patient tolerated the procedure
well with plan to extubate and transfer to recovery in stable condition.