clwilliamson
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Provider documented that he did a decompression laminectomy of L1, L2 and part of T12 with resection of neurofibroma at L1. Note is below. Would this get coded as 63282 and 63005-XS since it is on different levels? Any help is appreciated.
After the patient was appropriately prepped and draped, a midline incision was made from T12 down to L2. This was confirmed with AP and lateral x-rays. The incision was then carried in the deeper layers through the superficial and deep fascia, cutting the thoracolumbar fascia and then paraspinal muscles were elevated subperiosteally bilaterally using Cobb elevators. Self-retaining retractors were then placed and once again the x-ray was used to localize the L1 and then spinous processes of L1, T12 and L2 were removed. Complete laminectomy of L1 was carried out and then a portion of L2, or pretty much the entire L2 was resected and a portion of T12 was resected. Good hemostasis was secured by a combination of application of Gelfoam and application of bone wax and then the dura was inspected. There was a bulge at the level of L1. The MRI scan revealed the tumor was mostly located in the left side, so a 4-0 silk suture was placed in the midline and then the dura was opened using a groove director to direct the opening, which was then widened using the scissors. The dura was then retracted with several 4-0 silk stay sutures and the nerve roots were kind of pushed to the right side and then the tumor was visible through the CSF lying anteriorly. The tumor was then mobilized using careful dissection of the micro dissectors and the nerve root entering the tumor was visualized. It pretty much expanded into the tumor. There was no possibility of that being separated and this was stimulated with unipolar and bipolar stimulation with no results and then the tumor was then mobilized and the nerve roots coming off the distal part, were also stimulated with unipolar and bipolar stimulation and there was no evidence of any activity. Therefore, this nerve was also sacrificed after a bipolar electrocoagulation and tumor was freed and delivered en bloc. The intradural space was then irrigated with normal saline until the return was clear. The dura was then closed with running and interrupted sutures of 4-0 silk. It was lined with Gelfoam and after careful hemostasis and placement of the drain, the surgical incision was closed in anatomical layers in a routine fashion. Sterile surgical dressing was applied and the patient returned to recovery room in satisfactory condition
After the patient was appropriately prepped and draped, a midline incision was made from T12 down to L2. This was confirmed with AP and lateral x-rays. The incision was then carried in the deeper layers through the superficial and deep fascia, cutting the thoracolumbar fascia and then paraspinal muscles were elevated subperiosteally bilaterally using Cobb elevators. Self-retaining retractors were then placed and once again the x-ray was used to localize the L1 and then spinous processes of L1, T12 and L2 were removed. Complete laminectomy of L1 was carried out and then a portion of L2, or pretty much the entire L2 was resected and a portion of T12 was resected. Good hemostasis was secured by a combination of application of Gelfoam and application of bone wax and then the dura was inspected. There was a bulge at the level of L1. The MRI scan revealed the tumor was mostly located in the left side, so a 4-0 silk suture was placed in the midline and then the dura was opened using a groove director to direct the opening, which was then widened using the scissors. The dura was then retracted with several 4-0 silk stay sutures and the nerve roots were kind of pushed to the right side and then the tumor was visible through the CSF lying anteriorly. The tumor was then mobilized using careful dissection of the micro dissectors and the nerve root entering the tumor was visualized. It pretty much expanded into the tumor. There was no possibility of that being separated and this was stimulated with unipolar and bipolar stimulation with no results and then the tumor was then mobilized and the nerve roots coming off the distal part, were also stimulated with unipolar and bipolar stimulation and there was no evidence of any activity. Therefore, this nerve was also sacrificed after a bipolar electrocoagulation and tumor was freed and delivered en bloc. The intradural space was then irrigated with normal saline until the return was clear. The dura was then closed with running and interrupted sutures of 4-0 silk. It was lined with Gelfoam and after careful hemostasis and placement of the drain, the surgical incision was closed in anatomical layers in a routine fashion. Sterile surgical dressing was applied and the patient returned to recovery room in satisfactory condition