postsurgical changes

troupe327

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For a patient who is status post laminectomy with a fusion who is being seen for low back pain, and the final impression says "post surgical changes"

I have s/p laminectomy v4589, fusion v454. is there a code for post surgical changes?

Finding:

The vertebral body heights appear to be well maintained without fracture or
subluxation. Postoperative changes are present with evidence of lumbar fusion,
laminectomy and intervertebral disc spacers at L4-L5 and L5-S1. There is no
significant narrowing of the spinal canal or intervertebral foramina evident.
There is no significant osseous abnormality evident. The included lung bases
appear to be free of active disease.

Impression:
1. Postsurgical changes without significant narrowing of the spinal canal or
intervertebral foramina.
 

Jamie Dezenzo

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I would verify with the doctor 722.83 Lumbar Postlaminectomy Syndrome
Spinal disorder due to spinal laminectomy surgery (assign if documentation indicates that pain is due scar tissue formation following disc surgery)
 
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