mmonk
New
I'm new to spinal procedure coding and need help coding the following procedure:
PROCEDURE: LEFT L4-5, L5-S1 LAMINOTOMIES, FORAMENTOMIES, AND MEDIAL FACETECTOMIES.
THE SKIN INCISION WAS MARKED WITH FLUOROSCOPY. THE SKIN WAS INFILTRATED WITH 1% LIDOCAINE WITH EPINEPHRINE, AND A MIDLINE INCISION WAS MADE FOR L4 TO THE TOP OF S1. HEMOSTASIS WAS OBTAINED WITH BOVIE CAUTERY. SELF-RETAINING RETRACTORS WERE PLACED TO THE SOUND AND THE LUMBODORSAL FASCIA ON THE LEFT SIDE WAS CAUTERIZED AND SUBPERIOSTEAL DISSECTION WAS CARRIED OUT WITH BOVIE DISSECTION OVER THE L4, L5, NAD S1 LAMINAE AND FACET JOINTS.SELF-RETAINING MCCULLOCH RETRACTOR WAS PLACED INTO THE WOUND. THE PROPER LOCATION WAS MARKED WITH INTRAOPERATIVE FLUOROSCOPY. ON THE LEFT SIDE. USING THE STRYKER DRILL, I DRILLED OUT THE MEDIAL FACET AND INFERIOR L5 UNTIL THE YELLOW LIGAMENT WAS IDENTIFIED. USING THE OPERITING MISCROSCOPE, THE REMAINDER OF THE YELLOW LIGAMENT AND FORAMINOTOMY OVER THE S1 NERVE ROOT WAS PERFORMED WITH KERRISON RONGEURS BY DOING AN S1 LAMINOTOMY. MEDIAL FACETECTOMY WAS PERFORMED WITH KERRISON RONGEURS. REMAINDER OF THE LATERAL YELLOW LIGAMENT WAS REMOVED WITH KERRISON RONGEURS. THE FACETECTOMY WAS CARRIED DOWN FLUSH TO THE S1 PEDICLE. WITH THE USE OF THE OPERATING MISCROSCOPE, I DID INSPECT THE L5-S1 DISK SPACE. IT WAS COMPLETELY CALCIFIED AND FUSED. THEREFORE, NO DISK WORK COULD BE PERFORMED, ONLY DECOMPRESSION. ONCE THE S1 AND L5 NERVE ROOTS WERE DECOMPRESSED, HEMOSTASIS WAS OBTAINED WITH GELFOAM AND THROMBIN. THEN, THE RETRACTOR WAS REMOVED SUPERIORLY OVER L4-5, AND AGAIN THE MEDIAL FACET AND INFERIOR L4 LAMINA WERE DRILLED DOWN WITH THE STRYKER DRILL UNTIL THE YELLOW LIGAMENT WAS IDENTIFIED. THE EPIDURAL SPACE WAS ENTERED. REMAINDER OF THE YELLOW LIGAMENT WAS REMOVED WITH KERRISON RONGEURS. GENEROUS FORAMINOTOMY OVER THE L5 NERVE ROOT WAS PERFORMED BY PERFORMING AN L5 LAMINOTOMY. MEDIAL FACETECTOMIES WERE COMPLETED, AND AGAIN THE DISK SPACE WAS IDENTIFIED TO BE COMPLETELY FUSED AND NO DISK WORK COULD BE PERFORMED, DO I REMOVED A PORTION OF THE INFERIOR ARTUCULATING FACET TO CLEAR OUT ROOM FOR THE L4 NERVE ROOT. THERE WAS SCAR TISSUE OVER THE L4 NERVE ROOT. THIS WAS LYSED SHARPLY WITH THE NERVE HOOKS AND SOME OF THE SCAR TISSUE WAS ALSO REMOVED WITH KERRISON RONGEURS. THE L4, L5, AND S1 NERVE ROOTS WERE DECOMPRESSED. GELFOAM, THROMBIN WERE PLACED IN THE LAMINOTOMIZED REGION. THE WOUND WAS THOROUGHLY IRRIGATED WITH ANTIBIOTIC SALINE. RETRACTOR WAS REMOVED. THE LUMBODORSAL FASCIA WAS THEN CLOSED WITH INTERRUPTED 0 VICRYL SUTURE. SUBCUTANEOUS TISSUES CLOSED WITH 2-0 VICRYL SUTURE. SKIN WAS CLOSED WITH INTRACUTICULAR 3-0 MONOCRYL. DERMABOND WAS PLACED ONTO THE WOUND AND THE INCISION AND APPROPRIATE DRESSING APPLIED. PATIENT TAKEN TO RECOVERY ROOM IN STABLE CONDITION.
PROCEDURE: LEFT L4-5, L5-S1 LAMINOTOMIES, FORAMENTOMIES, AND MEDIAL FACETECTOMIES.
THE SKIN INCISION WAS MARKED WITH FLUOROSCOPY. THE SKIN WAS INFILTRATED WITH 1% LIDOCAINE WITH EPINEPHRINE, AND A MIDLINE INCISION WAS MADE FOR L4 TO THE TOP OF S1. HEMOSTASIS WAS OBTAINED WITH BOVIE CAUTERY. SELF-RETAINING RETRACTORS WERE PLACED TO THE SOUND AND THE LUMBODORSAL FASCIA ON THE LEFT SIDE WAS CAUTERIZED AND SUBPERIOSTEAL DISSECTION WAS CARRIED OUT WITH BOVIE DISSECTION OVER THE L4, L5, NAD S1 LAMINAE AND FACET JOINTS.SELF-RETAINING MCCULLOCH RETRACTOR WAS PLACED INTO THE WOUND. THE PROPER LOCATION WAS MARKED WITH INTRAOPERATIVE FLUOROSCOPY. ON THE LEFT SIDE. USING THE STRYKER DRILL, I DRILLED OUT THE MEDIAL FACET AND INFERIOR L5 UNTIL THE YELLOW LIGAMENT WAS IDENTIFIED. USING THE OPERITING MISCROSCOPE, THE REMAINDER OF THE YELLOW LIGAMENT AND FORAMINOTOMY OVER THE S1 NERVE ROOT WAS PERFORMED WITH KERRISON RONGEURS BY DOING AN S1 LAMINOTOMY. MEDIAL FACETECTOMY WAS PERFORMED WITH KERRISON RONGEURS. REMAINDER OF THE LATERAL YELLOW LIGAMENT WAS REMOVED WITH KERRISON RONGEURS. THE FACETECTOMY WAS CARRIED DOWN FLUSH TO THE S1 PEDICLE. WITH THE USE OF THE OPERATING MISCROSCOPE, I DID INSPECT THE L5-S1 DISK SPACE. IT WAS COMPLETELY CALCIFIED AND FUSED. THEREFORE, NO DISK WORK COULD BE PERFORMED, ONLY DECOMPRESSION. ONCE THE S1 AND L5 NERVE ROOTS WERE DECOMPRESSED, HEMOSTASIS WAS OBTAINED WITH GELFOAM AND THROMBIN. THEN, THE RETRACTOR WAS REMOVED SUPERIORLY OVER L4-5, AND AGAIN THE MEDIAL FACET AND INFERIOR L4 LAMINA WERE DRILLED DOWN WITH THE STRYKER DRILL UNTIL THE YELLOW LIGAMENT WAS IDENTIFIED. THE EPIDURAL SPACE WAS ENTERED. REMAINDER OF THE YELLOW LIGAMENT WAS REMOVED WITH KERRISON RONGEURS. GENEROUS FORAMINOTOMY OVER THE L5 NERVE ROOT WAS PERFORMED BY PERFORMING AN L5 LAMINOTOMY. MEDIAL FACETECTOMIES WERE COMPLETED, AND AGAIN THE DISK SPACE WAS IDENTIFIED TO BE COMPLETELY FUSED AND NO DISK WORK COULD BE PERFORMED, DO I REMOVED A PORTION OF THE INFERIOR ARTUCULATING FACET TO CLEAR OUT ROOM FOR THE L4 NERVE ROOT. THERE WAS SCAR TISSUE OVER THE L4 NERVE ROOT. THIS WAS LYSED SHARPLY WITH THE NERVE HOOKS AND SOME OF THE SCAR TISSUE WAS ALSO REMOVED WITH KERRISON RONGEURS. THE L4, L5, AND S1 NERVE ROOTS WERE DECOMPRESSED. GELFOAM, THROMBIN WERE PLACED IN THE LAMINOTOMIZED REGION. THE WOUND WAS THOROUGHLY IRRIGATED WITH ANTIBIOTIC SALINE. RETRACTOR WAS REMOVED. THE LUMBODORSAL FASCIA WAS THEN CLOSED WITH INTERRUPTED 0 VICRYL SUTURE. SUBCUTANEOUS TISSUES CLOSED WITH 2-0 VICRYL SUTURE. SKIN WAS CLOSED WITH INTRACUTICULAR 3-0 MONOCRYL. DERMABOND WAS PLACED ONTO THE WOUND AND THE INCISION AND APPROPRIATE DRESSING APPLIED. PATIENT TAKEN TO RECOVERY ROOM IN STABLE CONDITION.