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Could someone please help with coding this report? We originally used CPT 22864 but now one of the physicians is saying there should be more codes...
Diagnosis: Cervical spondylosis without myelopathy
Procedures Performed:
1. Exploration of previous insertion of artificial disk at C5-C6
2. Removal of artificial disk at C5-C6
3. Preparation of inferior endplate of C5
4. Preparation of endplate of C6
5. Decompressive neuroforaminotomies bilaterally at C6
6. Insertion of interbody device at C5-C6
7. Use of allograft
8. Anterior plating C5-C6
9. Use of C-arm fluoroscopy
10. Use of microscopy
Description of procedure in detail: The patient was brought to the operating room and was placed in the supine position on the operating table. After adequate venous access had been obtained, the patient was induced with general anesthesia and was endotracheally intubated by anesthesia staff. One gram of Anxefprophylaxis was administered intravenously. The patient was electrically grounded. Bilateral lower extremity sequential compression devices were applied and a Foley catheter was inserted. The patients right next was prepped and draoed in the usual sterile fashion. C-arm fluoroscopy was admitted to the surgical field and the C5 to C6 level was localized before a surgical timeout was conducted. A #10 kin blade was used to make a skin incision which measured approximately 4cm and was oriented transversally between the lateral border of the trachea on the right and the ipsilateral sternocleidomastoid muscle. Incision was carried through the deep subcutaneous tissues, down to the level of the platysma muscle which was elevated and divided longitudinally in the line with its fibers. The medial gored of the sternocleidomastoid muscle was identified and the cervical fascial plane medial to this was dissected both bluntly and sharply to gain access to the precervical fascia of the cervical spine. Self-retaining retractors were inserted into the wound to maintain surgical exposure and the disscection continued along the anteripor margins of the spine at the C5 to C6 level as was localized by C-arm fluoroscopy. The operating microscope was admitted to the surgical field. Distractor pins were placed into the anterior portion of the vertebral bodies at C5 and C6 and gentle distraction afforded good surgical exposure at this level. Kocher forceps was used to grasp the polyethylene insert of artificial disk at C5 to C6 and was used to remove it in a single piece. An osteotome was then inserted between the inferior endplate of C5 and the superior disk plate. This allowed the disk palate to be removed. A similar maneuver was applied at the C6 level, also allowing the disk plate to be removed at that level. Decompressive neural foraminotomies were performed using 2 and 3 mm kerrison rongeurs bilaterally at C6. A blunt nerve hook was passed through the neural foramina at this level to ensure adequate decompression. Once this had been assured. The inferior endplate of X52 was cage packed with demineralized bone matrix was then inserted to adequate depth at the C5 to C6 level. A suitably sized plate was affied to the anterior portion at C5 and C6 using 2 titanium screws at each level. Insertion of all hardware was performed under and distractor pins were removed. The distractor pin holes were sealed with bone wax to achieve hemostais. Again, the field was irrigated with copious quantities of sterile irrigation before the platysma muscle was reapproximated using interrupted 3-0 Vicryl suture, which was also used in the subcuticular layer of the skin for reapproximation. The wound was cleansed and dried and 2 layers of Dermabond glue were used for final skin approximation. A sterile dressing was applied before the patient was undraped. He was awakened by anesthesia staff and was endotracheally extubated. Screening neurologix examination revealed no new overt focal neurologic deficits and the patient was transported awake and alert, moving all extremities to command to the postanesthesia recovery room. At the end of the procedure, all sponge, needle and instrument counts were correct. There were no intraoperative complications.
Diagnosis: Cervical spondylosis without myelopathy
Procedures Performed:
1. Exploration of previous insertion of artificial disk at C5-C6
2. Removal of artificial disk at C5-C6
3. Preparation of inferior endplate of C5
4. Preparation of endplate of C6
5. Decompressive neuroforaminotomies bilaterally at C6
6. Insertion of interbody device at C5-C6
7. Use of allograft
8. Anterior plating C5-C6
9. Use of C-arm fluoroscopy
10. Use of microscopy
Description of procedure in detail: The patient was brought to the operating room and was placed in the supine position on the operating table. After adequate venous access had been obtained, the patient was induced with general anesthesia and was endotracheally intubated by anesthesia staff. One gram of Anxefprophylaxis was administered intravenously. The patient was electrically grounded. Bilateral lower extremity sequential compression devices were applied and a Foley catheter was inserted. The patients right next was prepped and draoed in the usual sterile fashion. C-arm fluoroscopy was admitted to the surgical field and the C5 to C6 level was localized before a surgical timeout was conducted. A #10 kin blade was used to make a skin incision which measured approximately 4cm and was oriented transversally between the lateral border of the trachea on the right and the ipsilateral sternocleidomastoid muscle. Incision was carried through the deep subcutaneous tissues, down to the level of the platysma muscle which was elevated and divided longitudinally in the line with its fibers. The medial gored of the sternocleidomastoid muscle was identified and the cervical fascial plane medial to this was dissected both bluntly and sharply to gain access to the precervical fascia of the cervical spine. Self-retaining retractors were inserted into the wound to maintain surgical exposure and the disscection continued along the anteripor margins of the spine at the C5 to C6 level as was localized by C-arm fluoroscopy. The operating microscope was admitted to the surgical field. Distractor pins were placed into the anterior portion of the vertebral bodies at C5 and C6 and gentle distraction afforded good surgical exposure at this level. Kocher forceps was used to grasp the polyethylene insert of artificial disk at C5 to C6 and was used to remove it in a single piece. An osteotome was then inserted between the inferior endplate of C5 and the superior disk plate. This allowed the disk palate to be removed. A similar maneuver was applied at the C6 level, also allowing the disk plate to be removed at that level. Decompressive neural foraminotomies were performed using 2 and 3 mm kerrison rongeurs bilaterally at C6. A blunt nerve hook was passed through the neural foramina at this level to ensure adequate decompression. Once this had been assured. The inferior endplate of X52 was cage packed with demineralized bone matrix was then inserted to adequate depth at the C5 to C6 level. A suitably sized plate was affied to the anterior portion at C5 and C6 using 2 titanium screws at each level. Insertion of all hardware was performed under and distractor pins were removed. The distractor pin holes were sealed with bone wax to achieve hemostais. Again, the field was irrigated with copious quantities of sterile irrigation before the platysma muscle was reapproximated using interrupted 3-0 Vicryl suture, which was also used in the subcuticular layer of the skin for reapproximation. The wound was cleansed and dried and 2 layers of Dermabond glue were used for final skin approximation. A sterile dressing was applied before the patient was undraped. He was awakened by anesthesia staff and was endotracheally extubated. Screening neurologix examination revealed no new overt focal neurologic deficits and the patient was transported awake and alert, moving all extremities to command to the postanesthesia recovery room. At the end of the procedure, all sponge, needle and instrument counts were correct. There were no intraoperative complications.