How would you code this?
Diagnosis: Cervical arachnoid cyst with spinal cord syrinx
Procedure: C6-7 laminectomy, C3 laminectomy, fenestration of intradural arachnoid cyst, microscope and duraplasty
Procedure: The C3 lamina was identified as was the C6 and C7 lamina. These were fully exposed and laminectomy was performed at this level at C3 as well as C6-7/ once accomplished normal dura was identified. Meticulous dissection through previous scar tissue was undertaken to strip the scar tissue from the dura and expose the dura as well as lateral masses bilaterally. Once this was accomplished the previously noted dural repair was identified. This was incised and the dura was opened and tacked in place. The operating microosope was brought into the field using microsurgical technique and microdissection. Dense scar tissue was meticulously disssected from the spinal cord as well as nerve roots and dentate ligaments bilaterally. A fenestration was performed of a large anterior arachnoid cyst on the right side which was posteriorly displacing the spinal cord. Once this was accomplished a large dural graft was then sewn into the durotomy defect. This was about 8 cm in length. The wound was copiously irrigated out.
Thanks
Mary, CPC
Diagnosis: Cervical arachnoid cyst with spinal cord syrinx
Procedure: C6-7 laminectomy, C3 laminectomy, fenestration of intradural arachnoid cyst, microscope and duraplasty
Procedure: The C3 lamina was identified as was the C6 and C7 lamina. These were fully exposed and laminectomy was performed at this level at C3 as well as C6-7/ once accomplished normal dura was identified. Meticulous dissection through previous scar tissue was undertaken to strip the scar tissue from the dura and expose the dura as well as lateral masses bilaterally. Once this was accomplished the previously noted dural repair was identified. This was incised and the dura was opened and tacked in place. The operating microosope was brought into the field using microsurgical technique and microdissection. Dense scar tissue was meticulously disssected from the spinal cord as well as nerve roots and dentate ligaments bilaterally. A fenestration was performed of a large anterior arachnoid cyst on the right side which was posteriorly displacing the spinal cord. Once this was accomplished a large dural graft was then sewn into the durotomy defect. This was about 8 cm in length. The wound was copiously irrigated out.
Thanks
Mary, CPC