I am a recent graduate and I am a little stumped on this. This is the procedure that was done and the op report has my doc as "Panel 2: DR. - primary. In his report he states that he was present and scrubbed in for the entire procedure. The previous coder turned this into medicare with a 63303-62GC and it is being denied. This is a teaching hospital and my doc didn't do any of the procedure on that day. Should I use a 99360 for my doc? I'm not completely satisfied with this, but I'm not sure what else to do. Any help is greatly appreciated.
PROCEDURE: After the induction of general endotracheal anesthesia the
patient had undergone a decompression posteriorly. The patient was then
placed in a supine position on the operating table. The anterior abdomen was
prepped and appropriately draped. A midline abdominal incision was made.
The preperitoneal space was entered. The peritoneal cavity was separated
from the abdominal cavity with the dissection being carried to the patient's
left and the peritoneal cavity retracted to the patient's right. The left
ureter was retracted with the peritoneum to the patient's right. The L5-S1
disc space was exposed. The artery and vein were identified and ligated
with hemoclips and divided.
Appropriate retraction was placed. The segmental vessels over L4 were
divided. The tributaries including the iliolumbar vein and probably an
inferior vein were identified and ligated proximally with 2-0 Vicryl
ligature and hemoclips distally before division. This then allowed
retraction over the L4-L5 disc space and eventually over the entire L5
vertebral body.
Appropriate retractors were placed. The patient underwent a corpectomy as
described by Dr. Fassett in his note.
Following the corpectomy the retractors were removed. Excellent hemostasis
was noted. The trocars were removed and the fascia was closed with a
continuous running #1 PDS suture. The skin was closed with a continuos
running subcuticular suture. Dermabond was applied to the wound.
The patient then left the operating room in stable condition. There had
been minimal blood loss from the anterior portion of the procedure.
PROCEDURE: After the induction of general endotracheal anesthesia the
patient had undergone a decompression posteriorly. The patient was then
placed in a supine position on the operating table. The anterior abdomen was
prepped and appropriately draped. A midline abdominal incision was made.
The preperitoneal space was entered. The peritoneal cavity was separated
from the abdominal cavity with the dissection being carried to the patient's
left and the peritoneal cavity retracted to the patient's right. The left
ureter was retracted with the peritoneum to the patient's right. The L5-S1
disc space was exposed. The artery and vein were identified and ligated
with hemoclips and divided.
Appropriate retraction was placed. The segmental vessels over L4 were
divided. The tributaries including the iliolumbar vein and probably an
inferior vein were identified and ligated proximally with 2-0 Vicryl
ligature and hemoclips distally before division. This then allowed
retraction over the L4-L5 disc space and eventually over the entire L5
vertebral body.
Appropriate retractors were placed. The patient underwent a corpectomy as
described by Dr. Fassett in his note.
Following the corpectomy the retractors were removed. Excellent hemostasis
was noted. The trocars were removed and the fascia was closed with a
continuous running #1 PDS suture. The skin was closed with a continuos
running subcuticular suture. Dermabond was applied to the wound.
The patient then left the operating room in stable condition. There had
been minimal blood loss from the anterior portion of the procedure.