Question CPT 22630 VS 22633

mfournier

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Hello:

Hoping someone can clarify whether the following op note should be 22630 vs 22633.

If someone can point out if provider did do the combination approach as described in cpt 22633. That would be great.

I was thinking coding would be 22630 or 22633
22632 or 22634
22853 2 units or 22853, 22853,59
20930
20936

Thanks for any clarification.
Miriam


PREOPERATIVE DIAGNOSIS:
1. lumbar stenosis
2. lumbar osteoarthritis
POSTOPERATIVE DIAGNOSIS:
1. lumbar stenosis
2. lumbar osteoarthritis

PROCEDURE PERFORMED: posterior minimally invasive transforaminal lumbar interbody fusion L4 - L5 L5 - S1 with pedicle screws and cage, allograft, autograft, and neuromonitoring

REASON FOR OPERATION: This patient was evaluated and diagnosed with lumbar stenosis, for which surgical intervention was recommended, as per prior documentation. The patient was apprised of the benefits and risks of the procedure, with risks explained as including but not limited to potential infection, bleeding, cerebrospinal fluid leak, weakness or numbness, urinary problems, failure to improve or fuse, hoarseness or swallowing problems, need for further surgery, heart attack, pulmonary embolus or death. The patient expressed understanding of the issues involved, stated that all questions were answered satisfactorily, and signed the consent form.
OPERATION IN DETAIL: The patient was taken to the operating room, and following confirmation of operative side and site based on the medical record, was intubated under general endotracheal anesthesia. Neurophysiologic monitoring leads for upper and lower extremity motor-evoked and somatosensory-evoked potentials and triggered EMG were placed.The patient was rotated into the prone position on the Jackson table. All pressure points were padded. The skin of the back was prepped and draped in the standard sterile surgical fashion. The intraoperative fluoroscopy was used in the anterior-posterior dimension to localize incisions to access the pedicles of L4 - S1 and the skin incision was made with a #10 blade. Dissection was carried down to the level of the posterior lumbar fascia with the same instrument. This was divided, and the Jamshidi needles were inserted through the fasciotomies to dock on the transverse process and facet junction at the levels denoted above. The Jamshidi needles were impacted into the bone and impacted so as to advance the tip of the needle on the anterior-posterior radiographic projection from the lateral pedicle to the medial border of the pedicle with depth impaction of less than 2 cm. The internal stylet of the Jamshidi needles were removed, and replaced with K-wires. The K-wires were clamped out of the field. The microscope was then brought in. Dissection of the soft tissue off of the right sided L4 - L5 facet was then performed with the Bovie electrocautery. The serial dilators and the spotlight access tube were inserted followed by the static tube which was clamped to the bed and the light source was installed. The further clearance of soft tissue off of the facet was performed microscopically under direct visualization. The power drill and osteotome was used to perform the facetectomy and the Kerrison punch was used to remove ligament soft tissue of the neural foramen. Bovie electrocautery was used to achieve venous hemostasis. The triggered EMG was used to identify the locations of neural structures in the foramen. These were carefully retracted for the purpose of the annulotomy. Annulotomy was carried out with #11 blade. The osteotome was inserted into the interbody space followed by the serial dilators size 6 mm through 10 mm from the DePuy lateral Cougar set and the shaver was used to prepare the endplate along with a ring curette. Disk material was removed with a Kerrison punch and pituitary rongeur. The trial implant sizers were inserted into the interbody space and the 9 mm trial confirmed as appropriately sizes, and the trial removed. The DePuy Conduit interbody cage was then selected and packed with a combination of the bone from the facets morselized as autograft plus Vivigen allograft, and was inserted into interbody space and confirmed as acceptably positioned. The applicator was disconnected. Copious irrigation was performed. Hemostasis was satisfactory. The static tube was removed and repositioned on the left side at the L5 - S1 level and the level confirmation, facetectomy, annulotomy, discectomy, endplate preparation and implant sizing, packing and implantation was performed at the L5 - S1 level using the same technique as described above for the L4 - L5 level. The bony decortication at the L4 - L5 level on the left and the L5 - S1 level on the right was performed with a power drill down the fasciotomies bilaterally. Tap instrument was used down the K-wires to create the thread tract. The screws were inserted DePuy Viper 2 minimally invasive polyaxial titanium pedicle screw set. The stimulation of the screw heads was performed with the triggered EMG in order to rule out abnormal potentials past threshold and none were identified. The rods were selected in the appropriate curvature and secured across the screw heads with the set screws, which were finally tightened according to the requisite torque. The screw extensions were removed. The combination of the residual allograft and autograft mixture was packed down the fasciotomies to contact all bony decorticated surfaces. The wounds were then closed in layers interrupted 0 Vicryl sutures in the fascia followed by 3-0 Vicryl sutures dermis and running 4-0 Monocryl subcuticular stitch. Derma Bond was placed on the skin edges to seal them externally. No neurophysiologic monitoring changes were reported by the end of the procedure.
 
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