BCrandall
Guru
Hi Everyone,
I've got this inpatient note that I coded to 27280 with 715.15 ICD-9. These don't play nice together per the Cross Coder and our software and nothing else in the chart supports diagnosis codes that do match. Dr. is steadfast that his diagnosis is correct. Any suggestions would be appreciated.
Preoperative Diagnosis: Right sacroiliac arthrosis.
Postoperative Diagnosis: Right sacroiliac arthrosis.
Procedure: Right sacroiliac arthrodesis with bone grafting and internal fixation.
Brief Clinical Note: This is a female who was injured with essentially a direct blow to the right lateral pelvis. She has had some lumbar issues but had confirmatory sacroiliac injection confirming sacral pain and did not have a good response to medial branch blocks. Her radiographs and imaging studies showed significant degenerative change within the SI joint and her examination is highly provocative for SI pathology.
Operative Detail: General endotracheal anesthesia. Prone position with a Coonrad pillow. Appropriate padding and positioning of the extremities. Perioperative antibiotics. ChloraPrep and sterile draping in the standard fashion of the right buttock and hip area.
We used the Zyga system and basically brought fluoroscopy in and aligned the pelvis adequately and then found the trajectory of the two implants and marked them on the skin. This gave us our starting incision and through essentially a 1-inch incision we passed the dilator down to the iliac crest and a guide pin was placed and checking its position on multiple fluoroscopic views until we found it to be adequate. We were approaching the SI joint orthogonally. We then placed the dilator cannulas and then reamed up to the SI joint without penetrating the joint. This allowed us to then place the blades to essentially remove cartilage from the iliac side then the sacral side and then for further clearing creating an area for bone grafting. We used Grafton Putty and impacted it into the area. We then were able to drill across the SI joint into the sacrum and measured for implant and ended up placing a 12.5-mm x 60-mm SI joint fusion rod. Its position was checked on multiple views and found to be adequate and had excellent compression.
We then followed the trajectory for the 6.5 anti-rotation screw, placed the guide wire, checking its position on multiple views, and then placing the 6.5 x 15-mm anti-rotation screw.
Both wounds were irrigated. We closed with layers of subcutaneous Vicryl and staples for the skin. She had sterile dressings and was turned supine, awakened, extubated, and taken to the recovery area in satisfactory condition.
I've got this inpatient note that I coded to 27280 with 715.15 ICD-9. These don't play nice together per the Cross Coder and our software and nothing else in the chart supports diagnosis codes that do match. Dr. is steadfast that his diagnosis is correct. Any suggestions would be appreciated.
Preoperative Diagnosis: Right sacroiliac arthrosis.
Postoperative Diagnosis: Right sacroiliac arthrosis.
Procedure: Right sacroiliac arthrodesis with bone grafting and internal fixation.
Brief Clinical Note: This is a female who was injured with essentially a direct blow to the right lateral pelvis. She has had some lumbar issues but had confirmatory sacroiliac injection confirming sacral pain and did not have a good response to medial branch blocks. Her radiographs and imaging studies showed significant degenerative change within the SI joint and her examination is highly provocative for SI pathology.
Operative Detail: General endotracheal anesthesia. Prone position with a Coonrad pillow. Appropriate padding and positioning of the extremities. Perioperative antibiotics. ChloraPrep and sterile draping in the standard fashion of the right buttock and hip area.
We used the Zyga system and basically brought fluoroscopy in and aligned the pelvis adequately and then found the trajectory of the two implants and marked them on the skin. This gave us our starting incision and through essentially a 1-inch incision we passed the dilator down to the iliac crest and a guide pin was placed and checking its position on multiple fluoroscopic views until we found it to be adequate. We were approaching the SI joint orthogonally. We then placed the dilator cannulas and then reamed up to the SI joint without penetrating the joint. This allowed us to then place the blades to essentially remove cartilage from the iliac side then the sacral side and then for further clearing creating an area for bone grafting. We used Grafton Putty and impacted it into the area. We then were able to drill across the SI joint into the sacrum and measured for implant and ended up placing a 12.5-mm x 60-mm SI joint fusion rod. Its position was checked on multiple views and found to be adequate and had excellent compression.
We then followed the trajectory for the 6.5 anti-rotation screw, placed the guide wire, checking its position on multiple views, and then placing the 6.5 x 15-mm anti-rotation screw.
Both wounds were irrigated. We closed with layers of subcutaneous Vicryl and staples for the skin. She had sterile dressings and was turned supine, awakened, extubated, and taken to the recovery area in satisfactory condition.
...again, late response here that i hope you find helpful.....