CCANTER
Networker
I am trying to code the ICD 10 PCS inpatient procedure for this. Do i need to query the provider for type of graft non-autologous or autologous to code this as a spinal fusion? or would i code this possibly as a revision of internal fixation device in lumbosacral joint?
here is the op note
PROCEDURE PERFORMED:
1. Rod reinsertion, right side, with repeat right sided L5-S1 posterolateral fusion with debridement of bed near pedicle screw placement of graft .
2. Intraoperative SSEP/EMG monitoring and fluoroscopic imaging.
Patient was then flipped over prone on the table LS spine was then prepped and draped in the usual sterile manner. The previous incision was excised back to new wound edges, and then the construct was brought down on the right side. The right side was dissected down off the palpable L1 spinous process to the L1-2 facet joint and down onto the hardware from L2 to the sacrum, and then this isolated. We had the proprietary instrumentation to remove this hardware, and we could see how the rod had kicked out with the failure at that level. This screw was revised to a 7.5 mm 35 mm screw and the posterolateral fusion bed was debrided with the placement of more bone graft; we just shifted that around onto a new virgin surface a little lateral on the sacral ala. The rod was then contoured. We went with a 130 mm rod, longer, just to make sure that even if he had any other mobility or any other fall, that he would not kick this out. The setscrews were torqued down.
here is the op note
PROCEDURE PERFORMED:
1. Rod reinsertion, right side, with repeat right sided L5-S1 posterolateral fusion with debridement of bed near pedicle screw placement of graft .
2. Intraoperative SSEP/EMG monitoring and fluoroscopic imaging.
Patient was then flipped over prone on the table LS spine was then prepped and draped in the usual sterile manner. The previous incision was excised back to new wound edges, and then the construct was brought down on the right side. The right side was dissected down off the palpable L1 spinous process to the L1-2 facet joint and down onto the hardware from L2 to the sacrum, and then this isolated. We had the proprietary instrumentation to remove this hardware, and we could see how the rod had kicked out with the failure at that level. This screw was revised to a 7.5 mm 35 mm screw and the posterolateral fusion bed was debrided with the placement of more bone graft; we just shifted that around onto a new virgin surface a little lateral on the sacral ala. The rod was then contoured. We went with a 130 mm rod, longer, just to make sure that even if he had any other mobility or any other fall, that he would not kick this out. The setscrews were torqued down.