purplescarf23
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A co-worker and I are in debate as to what is correct for the OP note below. Here is option 1: 63266, 22610, 22614 and 20936
option 2: 63016, 22610, 22614, 20936
Any suggestions or advice is greatly appreciated. Thank you
Kelsey, CPC
PREOPERATIVE DIAGNOSES: 1. Epidural abscess at T10, T11, and
extension to T9.
2. Diskitis at T10-T11 disk.
3. Osteomyelitis of T10 and T11 without evidence of intraosseous
abscess (sequestrum).
POSTOPERATIVE DIAGNOSES: 1. Epidural abscess at T10, T11, and
extension to T9.
2. Diskitis at T10-T11 disk.
3. Osteomyelitis of T10 and T11 without evidence of intraosseous
abscess (sequestrum).
PROCEDURES: 1. Laminectomy at T9, laminectomy at T10, laminectomy at
T11.
2. UnInstrumented fusion with local autograft at T9-T10 and T10-T11.
SURGEON: XXXXX
ASSISTANT: None.
SPECIMENS: Two.
MICROBIOLOGY: Times 1.
DRAINS: Round JP times 1.
COMPLICATIONS: None.
DISPOSITION: PACU.
CONDITION: Stable.
OPERATIVE INDICATIONS: Worsening low back pain with radiographic
diagnosis of diskitis and osteomyelitis, but with epidural extension
and evidence of neural compression at the level of T10-T11 due to
epidural abscess and phlegmon with extension to more cephalad level.
OPERATIVE DETAILS: The patient was met in the preoperative holding
area. Her operative thoracic spine was identified and marked.
Received antibiotics prior to the skin incision due to a protracted
course of preoperative antibiotics. Was brought to the OR and
positioned on the table in the prone position and all bony prominences
well padded after the induction of general endotracheal anesthesia.
Time taken out to identify the correct lumbar spine, and she was
prepped with triple preparation of chlorhexidine gluconate before
localization of the levels with spinal needles. Extensive and careful
localization of spinal needles was undertaken, counting up from the
sacrum with placement of multiple needles as landmarks into the lumbar
spine, into the thoracolumbar junction and finally into the thoracic
spine. Intraoperative CT fluoroscopy and cone beam CT reconstructions
were obtained to finally localize the levels. Dr. X
performed intraoperative consultation for localization of levels, and
both Drs. X and X agreed on the initial localization
(localization #1) from the level of T9 to T11. The skin was marked,
and the patient was prepped and draped in the standard sterile
fashion.
The skin incision was made longitudinally with the use of a 10-blade
scalpel, and dissection was taken down to the level of the fascia.
Self-retaining retractors were placed and hemostasis was assured with
the use of argon beam electrocautery and then dissection was deepened
with the use of Bovie electrocautery and self-retaining retractors
were placed to expose the spinous processes and lamina in sequence.
Care was taken to identify and prefer the facette capsules at every
level and the dissection was widened, sparing the capsules and to
expose the lamina and the interspace at the involved levels.
At this point, an extensive second localization was undertaken with
the use of C-arm fluoroscopy. Multiple spinal needles were again
replaced from the lumbar spine into the thoracolumbar junction into
the thoracic spine, and the levels were counted from below. A curette
was placed in the interspace, and a CoCr was placed on the spinous
process of the involved levels, T10-T11. Dr. X again
performed intraoperative consultation for the second and final
localization of the operative levels. Both Drs. X and X agreed that the involved levels were identified as the T10 and T11
interspace, T10 lamina to the T11 lamina, and the T9 lamina and T9-T10
interspace as desired. An indelible mark was made with the use of a
rongeur at the level of the T10-T11 interspace. Decompression was
then undertaken with the use of a rongeur, a high-speed burr with a 4-
mm ball tip, and the use of a #2, #3, #4 and #5 kerrison.
Care was taken to resect all the ligamentum flavum, as well as bone of
the lamina. Facette capsules were continued to be preserved, and a
narrow midline decompression was undertaken and ordered to assure
stability of the lateral stabilizing structures and facetectomy was
not required. Intraoperative cultures were obtained, and evidence of
the intraoperative visualization of phlegmon was confirmed. This was
completely evacuated and irrigated. Once the dorsal midline
decompression was undertaken, a long ball-tip probe was introduced
into the epidural space laterally on the right side and on the left
side and was placed ventrally onto the dorsal aspect of the vertebral
body. It was then rotated into the ventral epidural space in order to
ensure complete destruction of any adhesions and complete evacuation
of any retained epidural collection. This was found to be
satisfactory, and the epidural space was copiously irrigated at
multiple levels with warm saline with the probe rotated and placed to
decompress the ventral epidural space. A Penfield 4 was gently
introduced laterally to the spinal cord and dura to the T10-T11 disk
space to decompress any retained phlegmon or collection that was
intradiscal. The wounds were again then copious irrigated with a
liter of warm saline and hemostasis was assured with the use of
hemostatic agents and bipolar cautery and bone wax. The
decompression, as well as the evacuation of the collection was found
to be very satisfactory in the spinal cord and dura. Those levels
were completely decompressed. Decortication of the transverse
processes and rib heads was undertaken, and bone graft, which was
local autograft, and found to have no evidence of infection on gross
inspection, was morcellized and placed in the gutters at the T9-T10
and T10-T11 intervals. A drain was placed and the wound was closed in
layers with the use of 1-0 Vicryl, 2-0 Vicryl and nylon sutures. The
skin was cleansed with wet-to-dry gauze and a sterile
dressing built up of drain sponge, Xeroform gauze, 4 x 4's, ABG pad
and foam tape.
The drapes were taken down. All sponge and needle counts were
correct. There were no complications. The patient tolerated the
procedure well and was discharged to the PACU in good condition after
extubation.
option 2: 63016, 22610, 22614, 20936
Any suggestions or advice is greatly appreciated. Thank you
Kelsey, CPC
PREOPERATIVE DIAGNOSES: 1. Epidural abscess at T10, T11, and
extension to T9.
2. Diskitis at T10-T11 disk.
3. Osteomyelitis of T10 and T11 without evidence of intraosseous
abscess (sequestrum).
POSTOPERATIVE DIAGNOSES: 1. Epidural abscess at T10, T11, and
extension to T9.
2. Diskitis at T10-T11 disk.
3. Osteomyelitis of T10 and T11 without evidence of intraosseous
abscess (sequestrum).
PROCEDURES: 1. Laminectomy at T9, laminectomy at T10, laminectomy at
T11.
2. UnInstrumented fusion with local autograft at T9-T10 and T10-T11.
SURGEON: XXXXX
ASSISTANT: None.
SPECIMENS: Two.
MICROBIOLOGY: Times 1.
DRAINS: Round JP times 1.
COMPLICATIONS: None.
DISPOSITION: PACU.
CONDITION: Stable.
OPERATIVE INDICATIONS: Worsening low back pain with radiographic
diagnosis of diskitis and osteomyelitis, but with epidural extension
and evidence of neural compression at the level of T10-T11 due to
epidural abscess and phlegmon with extension to more cephalad level.
OPERATIVE DETAILS: The patient was met in the preoperative holding
area. Her operative thoracic spine was identified and marked.
Received antibiotics prior to the skin incision due to a protracted
course of preoperative antibiotics. Was brought to the OR and
positioned on the table in the prone position and all bony prominences
well padded after the induction of general endotracheal anesthesia.
Time taken out to identify the correct lumbar spine, and she was
prepped with triple preparation of chlorhexidine gluconate before
localization of the levels with spinal needles. Extensive and careful
localization of spinal needles was undertaken, counting up from the
sacrum with placement of multiple needles as landmarks into the lumbar
spine, into the thoracolumbar junction and finally into the thoracic
spine. Intraoperative CT fluoroscopy and cone beam CT reconstructions
were obtained to finally localize the levels. Dr. X
performed intraoperative consultation for localization of levels, and
both Drs. X and X agreed on the initial localization
(localization #1) from the level of T9 to T11. The skin was marked,
and the patient was prepped and draped in the standard sterile
fashion.
The skin incision was made longitudinally with the use of a 10-blade
scalpel, and dissection was taken down to the level of the fascia.
Self-retaining retractors were placed and hemostasis was assured with
the use of argon beam electrocautery and then dissection was deepened
with the use of Bovie electrocautery and self-retaining retractors
were placed to expose the spinous processes and lamina in sequence.
Care was taken to identify and prefer the facette capsules at every
level and the dissection was widened, sparing the capsules and to
expose the lamina and the interspace at the involved levels.
At this point, an extensive second localization was undertaken with
the use of C-arm fluoroscopy. Multiple spinal needles were again
replaced from the lumbar spine into the thoracolumbar junction into
the thoracic spine, and the levels were counted from below. A curette
was placed in the interspace, and a CoCr was placed on the spinous
process of the involved levels, T10-T11. Dr. X again
performed intraoperative consultation for the second and final
localization of the operative levels. Both Drs. X and X agreed that the involved levels were identified as the T10 and T11
interspace, T10 lamina to the T11 lamina, and the T9 lamina and T9-T10
interspace as desired. An indelible mark was made with the use of a
rongeur at the level of the T10-T11 interspace. Decompression was
then undertaken with the use of a rongeur, a high-speed burr with a 4-
mm ball tip, and the use of a #2, #3, #4 and #5 kerrison.
Care was taken to resect all the ligamentum flavum, as well as bone of
the lamina. Facette capsules were continued to be preserved, and a
narrow midline decompression was undertaken and ordered to assure
stability of the lateral stabilizing structures and facetectomy was
not required. Intraoperative cultures were obtained, and evidence of
the intraoperative visualization of phlegmon was confirmed. This was
completely evacuated and irrigated. Once the dorsal midline
decompression was undertaken, a long ball-tip probe was introduced
into the epidural space laterally on the right side and on the left
side and was placed ventrally onto the dorsal aspect of the vertebral
body. It was then rotated into the ventral epidural space in order to
ensure complete destruction of any adhesions and complete evacuation
of any retained epidural collection. This was found to be
satisfactory, and the epidural space was copiously irrigated at
multiple levels with warm saline with the probe rotated and placed to
decompress the ventral epidural space. A Penfield 4 was gently
introduced laterally to the spinal cord and dura to the T10-T11 disk
space to decompress any retained phlegmon or collection that was
intradiscal. The wounds were again then copious irrigated with a
liter of warm saline and hemostasis was assured with the use of
hemostatic agents and bipolar cautery and bone wax. The
decompression, as well as the evacuation of the collection was found
to be very satisfactory in the spinal cord and dura. Those levels
were completely decompressed. Decortication of the transverse
processes and rib heads was undertaken, and bone graft, which was
local autograft, and found to have no evidence of infection on gross
inspection, was morcellized and placed in the gutters at the T9-T10
and T10-T11 intervals. A drain was placed and the wound was closed in
layers with the use of 1-0 Vicryl, 2-0 Vicryl and nylon sutures. The
skin was cleansed with wet-to-dry gauze and a sterile
dressing built up of drain sponge, Xeroform gauze, 4 x 4's, ABG pad
and foam tape.
The drapes were taken down. All sponge and needle counts were
correct. There were no complications. The patient tolerated the
procedure well and was discharged to the PACU in good condition after
extubation.
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