Enough info to code anterior fusion?

JenReyn99

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I am not sure I have enough info to code a fusion. Input appreciated.

Here's the info I have:

...Retroperitoneal exposure to the anterior lumbar spine. Following the exposure, the fluoroscopic C-arm was brought in to confirm levels. Discectomy was then performed with removal of the anterior annular fibers, the nucleus pulposus, and cartilaginous endplates. The bony endplates were decorticated for fusion. The disc space was kept distracted moderately. Special attention was paid to not over distracting. A synthetic cage construct was then chosen of the appropriate size. It was filled with INFUSE and cancellous allograft and this construct was stamped in for a good fit. A Buttress screw was then placed at the anterior superior sacrum. This will help keep the cage from dislodging anteriorly due to the obliquity of this segment.....

That's what I have to code from. He doesn't list segment except in the operation name. He lists there as L5-S1.

Help!!!
 

ewinnacott

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Theres not enough information. The surgeon needs to put what segments/spaces he put the cage in besides the operation name. I would request an addendum or if possible to edit the note somehow
 
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