The phys. say he performed one with interbody at one level and the second level he didn't. So I am not sure how to code this. I know you cannot bill the two codes together so I do I just use 22633?
I am posting the op not for review. Please help
1. Spinal stenosis with claudication 724.03.
2. Lumbar radiculopathy 724.4.
3. Lumbar spondylosis 721.3.
4. Instability and degenerative spondylolisthesis 738.4.
POSTOPERATIVE DIAGNOSIS:
1. Spinal stenosis with claudication 724.03.
2. Lumbar radiculopathy 724.4.
3. Lumbar spondylosis 721.3.
4. Instability and degenerative spondylolisthesis 738.4.
PROCEDURES:
1. Laminectomy L2, L3, L4 and partial L5.
2. Bilateral foraminotomy and facetectomy L2-3, L3-4, L4-5.
3. Transforaminal lumbar interbody fusion interbody fusion L4-5.
4. Instrumentation and posterior lateral gutter fusion L2-L5.
5. Salvage autograft from same incision.
6. Morselized DBM graft on allograft.
COMPLICATIONS:
None apparent.
ESTIMATED BLOOD LOSS:
150 mL.
IMPLANTS:
1. Medtronic Solera screws 7.5 x 50 and 45. The 45 mm screws were placed at
L5.
2. Elevate interbody titanium PEEK spacer 7 mm in height, 11 degrees of
lordosis and 28 degrees of length.
DESCRIPTION OF PROCEDURE IN DETAIL:
The patient was brought to the operative suite on 09/02/2015. A time-out was
performed by all members of the team. General anesthesia was induced. Foley
catheter was placed. He was placed in a prone position on the radiolucent 4-
post Jackson frame. Care was taken to pad the eyes, all bony prominences as
well as the chin and ulnar nerves bilaterally. Next, after we were satisfied
with the positioning we then prepped the back and draped out in the usual
sterile fashion. Fluoro was used to plan out the skin incision.
Dissection was carried down through skin subcutaneous tissue to level
lumbodorsal fascia. Subperiosteal dissection was carried out onto the spinous
processes and lamina of L2, L3, L4 and L5. Care was taken to preserve the
cephalad facet capsule of the L1-2 at the upper level of instrumentation not
to violate it.
Next, we placed instrumentation bilaterally with the use of direct anatomic
landmarks and tactile feel each pedicle pathway was started with an AM-8
matchstick bur followed by a Steffee probe, and then finally sounded with 4
walls of the floor. There is no evidence of breach.
Next, 7.5 x 50 mm screws were placed at each level with the exception being 45
mm screws placed at L5. Following this, we performed a total facetectomy 1st
with the use of an osteotome removing the inferior articular process of L4, L3
and L2 respectively. We then performed a lobster tail technique where we
removed the remaining lamina en bloc together in 1 large piece. We then
worked on the lateral recess on each side to complete the facetectomy and
foraminotomy taking special attention to completely decompress the left-sided
exiting L4 root to identify prior to TLIF procedure. The epidural space was
then cleared of veins and the underlying disk was noted. A 15 blade knife was
used to perform an annulotomy. The entire disk material was gutted out with
pituitary rongeur, curettes and Kerrisons in the usual fashion. We then
trialed and decided upon a final implant of a 7 x 28 with 12 degree lordosis
expandable Elevate type instrumentation after full disk space preparation was
complete, we packed autograft anterior to the cage as well as DBM graft on
putty. We then impacted the cage, expanded under fluoroscopy, checked the
final position, and then finally decorticated the transverse prostheses in the
lateral gutter and placed the additional bone graft including autograft and
DBM graft on mixed together. We copiously irrigated, per our standard
protocol with Betadine and saline. We then again irrigated with saline and
antibiotic irrigation, placed vancomycin powder topically within the wound,
placed a drain deep to the lumbodorsal fascia and closed the wound in a
routine layered fashion with interrupted Vicryl followed by Monocryl in the
skin and Dermabond. The patient was taken to the PACU in stable condition.
Please note the neural monitoring was used to test all screws which were
tested up to a level 20 with no evidence of a breach at all. We took final x-
rays and were satisfied with the position of everything. The patient was
taken to PACU.
I am posting the op not for review. Please help
1. Spinal stenosis with claudication 724.03.
2. Lumbar radiculopathy 724.4.
3. Lumbar spondylosis 721.3.
4. Instability and degenerative spondylolisthesis 738.4.
POSTOPERATIVE DIAGNOSIS:
1. Spinal stenosis with claudication 724.03.
2. Lumbar radiculopathy 724.4.
3. Lumbar spondylosis 721.3.
4. Instability and degenerative spondylolisthesis 738.4.
PROCEDURES:
1. Laminectomy L2, L3, L4 and partial L5.
2. Bilateral foraminotomy and facetectomy L2-3, L3-4, L4-5.
3. Transforaminal lumbar interbody fusion interbody fusion L4-5.
4. Instrumentation and posterior lateral gutter fusion L2-L5.
5. Salvage autograft from same incision.
6. Morselized DBM graft on allograft.
COMPLICATIONS:
None apparent.
ESTIMATED BLOOD LOSS:
150 mL.
IMPLANTS:
1. Medtronic Solera screws 7.5 x 50 and 45. The 45 mm screws were placed at
L5.
2. Elevate interbody titanium PEEK spacer 7 mm in height, 11 degrees of
lordosis and 28 degrees of length.
DESCRIPTION OF PROCEDURE IN DETAIL:
The patient was brought to the operative suite on 09/02/2015. A time-out was
performed by all members of the team. General anesthesia was induced. Foley
catheter was placed. He was placed in a prone position on the radiolucent 4-
post Jackson frame. Care was taken to pad the eyes, all bony prominences as
well as the chin and ulnar nerves bilaterally. Next, after we were satisfied
with the positioning we then prepped the back and draped out in the usual
sterile fashion. Fluoro was used to plan out the skin incision.
Dissection was carried down through skin subcutaneous tissue to level
lumbodorsal fascia. Subperiosteal dissection was carried out onto the spinous
processes and lamina of L2, L3, L4 and L5. Care was taken to preserve the
cephalad facet capsule of the L1-2 at the upper level of instrumentation not
to violate it.
Next, we placed instrumentation bilaterally with the use of direct anatomic
landmarks and tactile feel each pedicle pathway was started with an AM-8
matchstick bur followed by a Steffee probe, and then finally sounded with 4
walls of the floor. There is no evidence of breach.
Next, 7.5 x 50 mm screws were placed at each level with the exception being 45
mm screws placed at L5. Following this, we performed a total facetectomy 1st
with the use of an osteotome removing the inferior articular process of L4, L3
and L2 respectively. We then performed a lobster tail technique where we
removed the remaining lamina en bloc together in 1 large piece. We then
worked on the lateral recess on each side to complete the facetectomy and
foraminotomy taking special attention to completely decompress the left-sided
exiting L4 root to identify prior to TLIF procedure. The epidural space was
then cleared of veins and the underlying disk was noted. A 15 blade knife was
used to perform an annulotomy. The entire disk material was gutted out with
pituitary rongeur, curettes and Kerrisons in the usual fashion. We then
trialed and decided upon a final implant of a 7 x 28 with 12 degree lordosis
expandable Elevate type instrumentation after full disk space preparation was
complete, we packed autograft anterior to the cage as well as DBM graft on
putty. We then impacted the cage, expanded under fluoroscopy, checked the
final position, and then finally decorticated the transverse prostheses in the
lateral gutter and placed the additional bone graft including autograft and
DBM graft on mixed together. We copiously irrigated, per our standard
protocol with Betadine and saline. We then again irrigated with saline and
antibiotic irrigation, placed vancomycin powder topically within the wound,
placed a drain deep to the lumbodorsal fascia and closed the wound in a
routine layered fashion with interrupted Vicryl followed by Monocryl in the
skin and Dermabond. The patient was taken to the PACU in stable condition.
Please note the neural monitoring was used to test all screws which were
tested up to a level 20 with no evidence of a breach at all. We took final x-
rays and were satisfied with the position of everything. The patient was
taken to PACU.