Wiki Help coding procedure

Alfaro33

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Coral Springs, Florida
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Hello.

Any help with this procedure would be appreciated!


Preoperative Diagnosis
T12 burst fracture with retropulsion

Postoperative Diagnosis
Same

Operation
T11 through L1 segmental instrumented fusion
T12 spine Jack procedure/vertebral augmentation
Open reduction of spinal fracture

Anesthesia
GETA

Technique
Patient was flipped prone onto the operating room table which was a Jackson table. All bony prominences and pressure points were urged her to be well padded and free of pressure. Arms were placed above head in Superman position. AP and lateral C-arm fluoroscopy were then brought into place in the fracture of T12 was identified. The back was then cleansed with alcohol. The skin was then prepped and draped in the usual sterile fashion. A time-out was performed by the attending neurosurgeon. Starting points for the T11, T12, L1 pedicles were identified bilaterally. Incisions were infiltrated with 0.25% Marcaine with epinephrine 10 cc was utilized to tele. Incision was made using a 10. Blade over the bilateral pedicles of T11. Bovie electrocautery was used to obtain hemostasis and the fascia was sharply incised. Using the Jamshidi needles the pedicles were cannulated in a percutaneous technique. Nitinol K-wires were left in place. This procedure was then performed over the pedicles of L1 vertebrae as well. Both pedicles were cannulated and Nitinol wires were left in place. Next incisions were made bilaterally over the pedicle of T12. Again the hemostasis was obtained using Bovie electrocautery. The fascia was sharply incised. Jamshidi so were placed into the pedicles bilaterally and into the vertebral body of T12. Nitinol wires were placed down the Jamshidi is a. Next the hand drill was used to the appropriate depth and the wire was removed. The inner cannula was then removed and the spacers/trial was placed bilaterally. Next the spine Jack's were inserted and ensured to be in the appropriate trajectory on AP fluoroscopy. The Jack's were then bilaterally opened under AP and lateral fluoroscopy. After satisfactory realignment in expansion of the vertebral body repeat the Jack's were disengaged. Next cement was used down the cannulas bilaterally under AP and lateral fluoroscopy until satisfactory cement placement had been obtained. There was no egress into the canal or into the disc space. The cannulas there were then removed. 55 mm rods were then placed subfascial E from the L1 vertebrae to the T11 vertebrae. Locking caps were tightened over the L1 pedicle screws. Next under lateral fluoroscopy downward pressure was used to obtain ligamentous taxis and I was able to observe the fragment of T12 pullback into the body and the locking caps were then tightened over the T11 vertebral body. Thus reducing fracture. Next the wound was copiously irrigated. 5 cc of DBM was then used around the Tulip heads. The fascia was then closed using 2-0 interrupted Vicryl sutures. The skin was then closed in layers using combination of 2-0 interrupted Vicryl sutures and glue for the skin. Patient tolerated the procedure well. All counts were correct. There were no complications.
 
This case is a bit tricky. This provider should document the Neurosurgeon's Role in this procedure. The Procedure listed is T11 through L1 segmental instrumented fusion however an arthrodesis(fusion) is not documented here. There is no decortication nor bone grafting documented. Cement Augmentation is not coded separately. Assuming this is the Ortho Surgeons note you could code 22327,22842 but this would depend on if the Neurosurgeon performed Decompression T11-L1. Decompression is included in Open Reduction so this might need to be coded 22327-62. I would inquiry and look at both notes. Sorry I could not be of more help.
 
This case is a bit tricky. This provider should document the Neurosurgeon's Role in this procedure. The Procedure listed is T11 through L1 segmental instrumented fusion however an arthrodesis(fusion) is not documented here. There is no decortication nor bone grafting documented. Cement Augmentation is not coded separately. Assuming this is the Ortho Surgeons note you could code 22327,22842 but this would depend on if the Neurosurgeon performed Decompression T11-L1. Decompression is included in Open Reduction so this might need to be coded 22327-62. I would inquiry and look at both notes. Sorry I could not be of more help.
This is great information. Thank you!
 
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