Hi all,
So our provider performed an MLD on this pt and I have majority of the codes down, I just can't seem to figure one out. Can anyone help solve this mystery?
Procedure:
1. LT L5 hemilaminotomy, medial fasciotomy and foraminotomy.
2. Central decompression, ligamentectomy.
3. Decompression of the nerve root.
4. Decompression of the LT L5/S1 nerve root performing foraminotomies.
5. Application of fat graft to the epidural space.
6. Resection of partial calcified disc L5/S1. Modifier 22 will be used because of the degree of difficulty.
7. Intraoperative microdissection using operative microscope.
8. Intraoperative use and interpretation of fluoroscopy.
9. LT L5/S1 facet block.
Description of Procedure:
The patient was taken to the operating room and identified. She underwent an uneventful endotracheal intubation. Neuromonitoring leads were attached. The patient was placed prone on a Wilson frame. The back was pre-prepped. Fluoroscopic images obtained to localize the spine. The back was then prepped and draped in sterile fashion. Timeout was called by the circulating nurse. Microscope was brought to the field. The entire case was done under microscopic magnification. Incision was made in the midline after infiltration of local anesthetic. Dissection was carried down to the level of the subcutaneous fat using Bovie knife. The specimen of subcutaneous fat was then removed and placed in an antibiotic irrigation. Dissection was carried down to the level of the lumbar fascia. Using a Bovie knife lumbar-dorsal fascia was incised. Muscles were gently moved medially. The L5 hemilamina was exposed. Intraoperative fluoroscopic image was obtained to verify the correct level. Spine was localized using an instrument. Using high-speed drill, a left L5 hemilaminotomy was performed. The ligamentum flavum was identified. The hemilaminotomy was extended cephalad to the insertion of the ligamentum. The ligamentum flavum was then removed superficially and then completely in the lateral aspect. This exposed the S1 nerve root. There was a severe compromise of the S1 nerve root secondary to a disc herniation at the L5-S1 level. There was evidence of a calcific shell of the disc. The disc shell was then removed using a down pushing curette. Using pituitary rongeur, several large disc fragments were then removed to decompress the disc herniation. This provided significant decompression of the S1 nerve root anteriorly. The removal of disc was challenging secondary to the calcific nature and also there is severe compromise of the S1 nerve root. Modifier 22 will be used to indicate the difficulty in microdissection posed by this disc. At the end of decompression the disc space was irrigated with copious amount of antibiotic irrigation. S1 nerve root was completely free from compression within the foraminal space and at the disc space. Intraoperative neuromonitoring remained stable throughout the case. There was no evidence of intraoperative spinal fluid leak. The wound was irrigated with copious amount of antibiotic irrigation. Fat graft was then sized and then infiltrated with Marcaine and then placed over the epidural space, which provided excellent coverage of the dura and the nerve root. The L5-S1 facet capsule was identified. Using a 22-guage spinal needle, a facet block was obtained intraoperatively. Meticulous hemostasis was obtained throughout the case using a Gelfoam and bipolar cautery. Fascia was closed using 0 Vicryl stitches in an interrupted fashion. Subcutaneous tissue was closed using 2-0 Vicryl stitches in an interrupted fashion. Subcuticular layer was closed using 3-0 Vicryl stitches. The skin was dressed with Steri-Strips and Dermabond. Sterile dressing was applied. The patient was extubated at the end of the case moving all extremities. Instrument count was correct at the end of the case. The patient?s husband was fully informed regarding the intraoperative findings and the patient?s condition.
I came up with: 63030, 63042, 20926, 76000 but I am unaware what to list for the resection of the calcified disc. Any takers??
Thanks!!
So our provider performed an MLD on this pt and I have majority of the codes down, I just can't seem to figure one out. Can anyone help solve this mystery?
Procedure:
1. LT L5 hemilaminotomy, medial fasciotomy and foraminotomy.
2. Central decompression, ligamentectomy.
3. Decompression of the nerve root.
4. Decompression of the LT L5/S1 nerve root performing foraminotomies.
5. Application of fat graft to the epidural space.
6. Resection of partial calcified disc L5/S1. Modifier 22 will be used because of the degree of difficulty.
7. Intraoperative microdissection using operative microscope.
8. Intraoperative use and interpretation of fluoroscopy.
9. LT L5/S1 facet block.
Description of Procedure:
The patient was taken to the operating room and identified. She underwent an uneventful endotracheal intubation. Neuromonitoring leads were attached. The patient was placed prone on a Wilson frame. The back was pre-prepped. Fluoroscopic images obtained to localize the spine. The back was then prepped and draped in sterile fashion. Timeout was called by the circulating nurse. Microscope was brought to the field. The entire case was done under microscopic magnification. Incision was made in the midline after infiltration of local anesthetic. Dissection was carried down to the level of the subcutaneous fat using Bovie knife. The specimen of subcutaneous fat was then removed and placed in an antibiotic irrigation. Dissection was carried down to the level of the lumbar fascia. Using a Bovie knife lumbar-dorsal fascia was incised. Muscles were gently moved medially. The L5 hemilamina was exposed. Intraoperative fluoroscopic image was obtained to verify the correct level. Spine was localized using an instrument. Using high-speed drill, a left L5 hemilaminotomy was performed. The ligamentum flavum was identified. The hemilaminotomy was extended cephalad to the insertion of the ligamentum. The ligamentum flavum was then removed superficially and then completely in the lateral aspect. This exposed the S1 nerve root. There was a severe compromise of the S1 nerve root secondary to a disc herniation at the L5-S1 level. There was evidence of a calcific shell of the disc. The disc shell was then removed using a down pushing curette. Using pituitary rongeur, several large disc fragments were then removed to decompress the disc herniation. This provided significant decompression of the S1 nerve root anteriorly. The removal of disc was challenging secondary to the calcific nature and also there is severe compromise of the S1 nerve root. Modifier 22 will be used to indicate the difficulty in microdissection posed by this disc. At the end of decompression the disc space was irrigated with copious amount of antibiotic irrigation. S1 nerve root was completely free from compression within the foraminal space and at the disc space. Intraoperative neuromonitoring remained stable throughout the case. There was no evidence of intraoperative spinal fluid leak. The wound was irrigated with copious amount of antibiotic irrigation. Fat graft was then sized and then infiltrated with Marcaine and then placed over the epidural space, which provided excellent coverage of the dura and the nerve root. The L5-S1 facet capsule was identified. Using a 22-guage spinal needle, a facet block was obtained intraoperatively. Meticulous hemostasis was obtained throughout the case using a Gelfoam and bipolar cautery. Fascia was closed using 0 Vicryl stitches in an interrupted fashion. Subcutaneous tissue was closed using 2-0 Vicryl stitches in an interrupted fashion. Subcuticular layer was closed using 3-0 Vicryl stitches. The skin was dressed with Steri-Strips and Dermabond. Sterile dressing was applied. The patient was extubated at the end of the case moving all extremities. Instrument count was correct at the end of the case. The patient?s husband was fully informed regarding the intraoperative findings and the patient?s condition.
I came up with: 63030, 63042, 20926, 76000 but I am unaware what to list for the resection of the calcified disc. Any takers??
Thanks!!