coderguy1939
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Sugeon performed the following procedure:
"A temporary skin prep was made and a spinal needle was inserted into the left L5-S1 interspace. Intraoperative fluoroscopy was taken from the surgical incision level. The needle was removed. The lumbar spine was prepped and draped in the usual sterile fashion. Then, a 1-inch incision was made over the L5-S1 interspace based on the preoperative fluoroscopy. Next, the dermis and subdermal fat was incised. The lumbar dorsal fascia was incised along the spinal process of L5-S1. A Cobb elevator was used to subperiosteally dissect the paravertebral muscles of the L5-S1 lamina. THen, a self-retaining McCullough retractor was placed and an angled curette was inserted underneath the L5 lamina. Another flouroscopy shot was taken confirming the surgical level. Next, a microscope was draped and brought into the field and a high-speed bur was used to perform a partial laminectomy removing the right distal portion of the L5 and proximal portion of the S1 lamina. The laminectomy was then enlarged with a Kerrison rongeur. The ligamentum flavum was elevated and removed. Then, the thecal sac and traversing nerve root were visualized. They were noted to be quite adherent to the posterior aspect of the vertebral body and disc space at L5-S1. Therefore, a neurolysis was performed. Once this was done, the neural structures could be retracted to the midline revealing a very large intraspinal lesion consistent with the disc protrusion. Next, a #11 blade was used to incise the disc at L5-S1 and a combination of blunt-tip probe, angle curette and pituitary ronguer were used to evacuate the very large disc herniation in one or two large pieces. The effectively decompressed the central canal. There was noted to be a large posterior osteophyte of the L5-S1 vertebral body and therefore osteotomies were performed using curettes to remove the osteophytes thea were causing some mild central stenosis. Next, the Kerrison and angled curette was directed out to the foramen and decompressed in the far lateral region of the exiting L5 nerve root. Once this was done, there was no residual central or foraminal stenosis. Wound were copiously irrigated...", etc. I'm looking at 63030 for a procedure code. I'd like some other opinions, please. Thanks.
"A temporary skin prep was made and a spinal needle was inserted into the left L5-S1 interspace. Intraoperative fluoroscopy was taken from the surgical incision level. The needle was removed. The lumbar spine was prepped and draped in the usual sterile fashion. Then, a 1-inch incision was made over the L5-S1 interspace based on the preoperative fluoroscopy. Next, the dermis and subdermal fat was incised. The lumbar dorsal fascia was incised along the spinal process of L5-S1. A Cobb elevator was used to subperiosteally dissect the paravertebral muscles of the L5-S1 lamina. THen, a self-retaining McCullough retractor was placed and an angled curette was inserted underneath the L5 lamina. Another flouroscopy shot was taken confirming the surgical level. Next, a microscope was draped and brought into the field and a high-speed bur was used to perform a partial laminectomy removing the right distal portion of the L5 and proximal portion of the S1 lamina. The laminectomy was then enlarged with a Kerrison rongeur. The ligamentum flavum was elevated and removed. Then, the thecal sac and traversing nerve root were visualized. They were noted to be quite adherent to the posterior aspect of the vertebral body and disc space at L5-S1. Therefore, a neurolysis was performed. Once this was done, the neural structures could be retracted to the midline revealing a very large intraspinal lesion consistent with the disc protrusion. Next, a #11 blade was used to incise the disc at L5-S1 and a combination of blunt-tip probe, angle curette and pituitary ronguer were used to evacuate the very large disc herniation in one or two large pieces. The effectively decompressed the central canal. There was noted to be a large posterior osteophyte of the L5-S1 vertebral body and therefore osteotomies were performed using curettes to remove the osteophytes thea were causing some mild central stenosis. Next, the Kerrison and angled curette was directed out to the foramen and decompressed in the far lateral region of the exiting L5 nerve root. Once this was done, there was no residual central or foraminal stenosis. Wound were copiously irrigated...", etc. I'm looking at 63030 for a procedure code. I'd like some other opinions, please. Thanks.
