Fusion Surgery


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I have included a dictation that I need clarification on the coding... Would appreciate any help :)

PROCEDURE PERFORMED: Posterior lumbar interbody fusion at L3-L4, hemilaminectomy at L3, hemilaminectomy at L4, interbody cage placement, instrumentation at L3-L4, allograft, autograft, and fluoroscopy.

DETAILS OF THE OPERATION: The patient was brought into the operating room where general anesthesia was induced. She was placed prone on the operating room table. Fluoroscopy was used to localize the L3-L4 interspace.

The patient's back was prepped and draped in a sterilely surgical fashion. The surgical time-out was called. An incision was made with #10 blade. Dissection was carried out until such point that the lateral facet joint at the L3-L4 level was exposed. A lumbar subcutaneous retractor was placed. This was verified again with fluoroscopy. That was a correct level. At this point, a high-speed drill was brought in. Hemilaminectomies were performed at L3 and then at L4. The area was copiously irrigated. Hemostasis was obtained. At this point, a carbon fiber interbody cage was placed in the interspinous location. This was packed with allograft and autograft material. A spinous process clamp was then used to fixate the bodies of L3 and L4. Final tightening was performed. The lateral facet joints were decorticated. The area was copiously irrigated. Hemostasis was obtained. A final fluoroscopic image was obtained. Closure was performed in a standard layered fashion using 0 Vicryl sutures, 2-0 Vicryl sutures, and staples for skin. Specimen was sent to pathology.