Intra Operative consult or Procedure?

Coastal Coder

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Roanoke, VA
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Good Morning Everyone and Happy Friday,

Below is the note from An intra operative consult my Dr was called in for. The note reads as my Dr did a procedure to move the vascular structure to expose the cervical vertebrae. Is there a procedure here and if so what CPT would I use, or should I just bill an E/M code? Any help would be greatly appreciated.

Thanks,

Michelle



INDICATION FOR PROCEDURE:
The patient is a 59-year-old female, we were consulted intraoperatively. She was under anesthesia, the left cervical incision was made with exposure deep to the sternocleidomastoid, vascular structure was overlying the exposure to the cervical vertebral body and the omohyoid had been transected. We were asked to provide consultation and opinion regarding the structure and its mobilization. Counseling could not be obtained due to the patient under anesthesia.

PROCEDURE IN DETAIL:
The patient had been previously intubated, had been draped and prepped and exposure was as described above, applying further exposure with Weitlaner's as well as taking down the carotid sheath,the IJ was identified, mobilized and moved anterior to the surgical field to exposure the cervical vertebral bodies. There was no bleeding and no further intervention was performed. At this time the procedure was terminated to allow for Dr. George Huffmon to proceed with the indicated procedure.

DISPOSITION:
The patient will proceed as follows and will be called as necessary.
 

nickelclaw

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Peru, IN
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I would say no procedure was done. Sounds like he is just explaining what he saw and to verify that everything was ok.
From what I read sounds like an anterior approach to cervical disc procedure.
 
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