I'm trying to figure out how to code this op note for a pars defect repair.
A 7-10 centimeter incision was made over the dorsolumbar spine. The incision
was taken down to the level of the dorsolumbar fascia. The dorsolumbar fascia was
undermined using cautery, taken down to the level of the spinous process and the adjacent
lamina, all the way down to the pars defect and the facet joints. Once we were able to
fully delineate the borders of the TP, we were able to take our image scout film which
showed that we were certainly at L5. Once this was done, we were able to use the usual
landmarks to put two screws at L5 that were 4.0 X 30 millimeter screws, and then
subsequently we were able to take our incision dorsal to the fascia to the level of the
iliac crest on the right side and get some cancellous bone from the iliac crest and also
take some cortical cancellous bone strips. We were able to use, for the donor sites,
some Surgiflo following irrigation of the border and then we were able to close the
dorsolumbar fascia overlying that point of the iliac crest. Our attention was now taken
back to the wound where we were able to use the cancellous bone in the pars defect, and
subsequently we were able to decorticate the surface of the TP and the adjacent part of
the facet joints and put the cortical cancellous bone strips continuously from the TP to
the area overlying the pars defect where the cancellous bone was underneath the cortical
cancellous bone strip bilaterally. Once this was done, we were able to use an Atlas
cable going around the screw and under the spinous process and lamina and going to the
other screw and were able to compress that using a compression tightener. Once we did this to an appropriate degree, we were able to cut this wire and take x-rays that showed
that we were satisfied. We put a subfascial drain and closed the dorsolumbar fascia
using #1 Vicryl followed by #2 Vicryl for the subcutaneous tissue, and the skin was
closed using #2 nylon. The wound was dressed in a standard sterile fashion. The patient
was moved from the Wilson frame and taken to the Postanesthesia Care Unit with no
complications.
I got 22800 & 20937 but I'm not sure this is correct? Any assistance would be greatly appreciated.
Thanks, Meg
A 7-10 centimeter incision was made over the dorsolumbar spine. The incision
was taken down to the level of the dorsolumbar fascia. The dorsolumbar fascia was
undermined using cautery, taken down to the level of the spinous process and the adjacent
lamina, all the way down to the pars defect and the facet joints. Once we were able to
fully delineate the borders of the TP, we were able to take our image scout film which
showed that we were certainly at L5. Once this was done, we were able to use the usual
landmarks to put two screws at L5 that were 4.0 X 30 millimeter screws, and then
subsequently we were able to take our incision dorsal to the fascia to the level of the
iliac crest on the right side and get some cancellous bone from the iliac crest and also
take some cortical cancellous bone strips. We were able to use, for the donor sites,
some Surgiflo following irrigation of the border and then we were able to close the
dorsolumbar fascia overlying that point of the iliac crest. Our attention was now taken
back to the wound where we were able to use the cancellous bone in the pars defect, and
subsequently we were able to decorticate the surface of the TP and the adjacent part of
the facet joints and put the cortical cancellous bone strips continuously from the TP to
the area overlying the pars defect where the cancellous bone was underneath the cortical
cancellous bone strip bilaterally. Once this was done, we were able to use an Atlas
cable going around the screw and under the spinous process and lamina and going to the
other screw and were able to compress that using a compression tightener. Once we did this to an appropriate degree, we were able to cut this wire and take x-rays that showed
that we were satisfied. We put a subfascial drain and closed the dorsolumbar fascia
using #1 Vicryl followed by #2 Vicryl for the subcutaneous tissue, and the skin was
closed using #2 nylon. The wound was dressed in a standard sterile fashion. The patient
was moved from the Wilson frame and taken to the Postanesthesia Care Unit with no
complications.
I got 22800 & 20937 but I'm not sure this is correct? Any assistance would be greatly appreciated.
Thanks, Meg