NESmith
Expert
Please help me with the coding of this procedure.
Description of Procedure:
The patient was seen in the preoperative holding area where informed consent was verified. The surgical site was marked and anesthesia performed a thorough pre-operative evaluation. he was then taken to the operating theater where he was generally anesthetized. Neuromonitoring leads were applied and appropriate IV access was obtained. Timeout was called, confirming correct patient correct procedure, and that all necessart devices were available and prophylaticantibiotics were administered. he was sterilely prepped and draped in the standard fashion, and a midline incicion was made over the intended surgical levels and dissection was carried out down to the posterior elements. We confirmed our levels radiographically. we then dissected out to the tips of the transverse processes from L2 to bilateral scral ala. Bilateral posterior inferior iliac spines were exposed and iliac bolts were placed utilizing anatomical landmarks after obtaining autograft bone from the ileum bilaterally. We then performed bilateral posterior osteotomies, L2, L3, L4, and L5 in order to enhance the flexibility of the curvature, expose bony landmarks for screw placement, allow for complete foraminectomy on the patient's left side and denude the articular facets or cartilage. Following this we performed a complete laminectomyfrom the trailing edge of L2 to the leading edge of S1. The complete foraminectomies were performed at L3-4, L4-5 and L5-S1 on the patient's left side due to the severity of the stenosis. We then performed foraminotomies on the right side at L5-S1, L4-5, and L3-4. Once the decompression was felt to be adequate, we placed pedicle screws from S1-L2 in a sequential fashion starting on the left followed by the right. All screws were placed without difficulty and their position was confirmed radiographically as well as with pedicle stimulation. Following this, we placed the TLIF distractor at the L5-S1 disk space and in the standard fashion performed a diskectomy from the left side. A Boomerang Peek cage packed with autograft bone was placed into the disk space with autograft bone packed ventral to it. the same procedure was perfomred at L4-5 and L3-4. we then measured, cut and contoured rods and reduced the spine to the rods and placed a crosslink. We obtained intraoperative AP and lateral radiographs which showed acceptable placement of all implants. The residual posterior bony elements were decorticated and autograft bone and BMP were packed in the gutters as well as over the patient's right side at both posterior bony elements After copious amounts of antibiotic-laden sterile saline were run through the wound with a pulse lavage, we then placed a deep drain and closed the wound in layers. The patient awoke without event and was taken to the recovery room in stable condition. I was present for the entirety of the procedure.
Provder coded the procedure as such, but I am not sure if this is correct.
63030
63035 x 3
22842
22848
22558
22585 x 3
22630
22632 x 3
22851
20930
Thank You so much for your help.
Description of Procedure:
The patient was seen in the preoperative holding area where informed consent was verified. The surgical site was marked and anesthesia performed a thorough pre-operative evaluation. he was then taken to the operating theater where he was generally anesthetized. Neuromonitoring leads were applied and appropriate IV access was obtained. Timeout was called, confirming correct patient correct procedure, and that all necessart devices were available and prophylaticantibiotics were administered. he was sterilely prepped and draped in the standard fashion, and a midline incicion was made over the intended surgical levels and dissection was carried out down to the posterior elements. We confirmed our levels radiographically. we then dissected out to the tips of the transverse processes from L2 to bilateral scral ala. Bilateral posterior inferior iliac spines were exposed and iliac bolts were placed utilizing anatomical landmarks after obtaining autograft bone from the ileum bilaterally. We then performed bilateral posterior osteotomies, L2, L3, L4, and L5 in order to enhance the flexibility of the curvature, expose bony landmarks for screw placement, allow for complete foraminectomy on the patient's left side and denude the articular facets or cartilage. Following this we performed a complete laminectomyfrom the trailing edge of L2 to the leading edge of S1. The complete foraminectomies were performed at L3-4, L4-5 and L5-S1 on the patient's left side due to the severity of the stenosis. We then performed foraminotomies on the right side at L5-S1, L4-5, and L3-4. Once the decompression was felt to be adequate, we placed pedicle screws from S1-L2 in a sequential fashion starting on the left followed by the right. All screws were placed without difficulty and their position was confirmed radiographically as well as with pedicle stimulation. Following this, we placed the TLIF distractor at the L5-S1 disk space and in the standard fashion performed a diskectomy from the left side. A Boomerang Peek cage packed with autograft bone was placed into the disk space with autograft bone packed ventral to it. the same procedure was perfomred at L4-5 and L3-4. we then measured, cut and contoured rods and reduced the spine to the rods and placed a crosslink. We obtained intraoperative AP and lateral radiographs which showed acceptable placement of all implants. The residual posterior bony elements were decorticated and autograft bone and BMP were packed in the gutters as well as over the patient's right side at both posterior bony elements After copious amounts of antibiotic-laden sterile saline were run through the wound with a pulse lavage, we then placed a deep drain and closed the wound in layers. The patient awoke without event and was taken to the recovery room in stable condition. I was present for the entirety of the procedure.
Provder coded the procedure as such, but I am not sure if this is correct.
63030
63035 x 3
22842
22848
22558
22585 x 3
22630
22632 x 3
22851
20930
Thank You so much for your help.