DButcher
Contributor
Does Anyone have any thoughts on how to code this? I was looking at 63075 but that does not feel right.
PREOPERATIVE DIAGNOSIS:
Anterior osteophytes causing dysphagia at C2, C3 and C4.
POSTOPERATIVE DIAGNOSIS:
Same.
OPERATION:
1.* Removal of anterior osteophytes* at C2.
2.* Removal of anterior osteophyte* at C3.
3.* Removal of anterior osteophyte at C4.
EBL:* Minimal.
COMPLICATIONS:* None.
DISPOSITION:* Stable to recovery.
ANTIBIOTICS:* Two grams Ancef given 30 minutes prior to skin incision.
INDICATIONS:* The patient is an 84-year-old gentleman complaining anterior
dysphasia.* On CT scan and MRI, it was found that he had significant
osteophyte formation at C2, C3, C4.* Because
of this, we discussed about continuing nonoperative measures versus surgical
treatment, the patient elected for surgery.* He understood the general risks
of surgery not inclusive, but including bleeding, infection, anesthesia,
dysphagia, dysphonia, as well as nerve damage and neurovascular complaints.
BRIEF OPERATIVE COURSE:* Patient was met and greeted in preoperative holding. *
Patient had opportunity to ask all questions, all questions were answered. *
Patient was brought to the operating room.* Patient underwent general
anesthesia.* Timeout was performed.* Next, a longitudinal incision was made on
the left side of the neck.* We used a standard Smith Robinson approach, we
encountered a huge anterior osteophyte.* Using C-arm, we took down the anterior osteophytes* *
at C2, C3 and C4.* We palpated to make sure it was nice and flush.* Once it
was, we got C-arm to confirm that we had removed the anterior osteophyte and
it showed that we had removed with a significant amount of bony spurs.* Next,
we irrigated.* We placed bone wax to help with bleeding as well as help with
recurrent formation.* Once we were happy with that, we placed a drain exiting
the skin and we closed the fascia as well as the platysma with 2-0 Vicryl, 3-0
Monocryl.* I was present and participated in the entire case.
PREOPERATIVE DIAGNOSIS:
Anterior osteophytes causing dysphagia at C2, C3 and C4.
POSTOPERATIVE DIAGNOSIS:
Same.
OPERATION:
1.* Removal of anterior osteophytes* at C2.
2.* Removal of anterior osteophyte* at C3.
3.* Removal of anterior osteophyte at C4.
EBL:* Minimal.
COMPLICATIONS:* None.
DISPOSITION:* Stable to recovery.
ANTIBIOTICS:* Two grams Ancef given 30 minutes prior to skin incision.
INDICATIONS:* The patient is an 84-year-old gentleman complaining anterior
dysphasia.* On CT scan and MRI, it was found that he had significant
osteophyte formation at C2, C3, C4.* Because
of this, we discussed about continuing nonoperative measures versus surgical
treatment, the patient elected for surgery.* He understood the general risks
of surgery not inclusive, but including bleeding, infection, anesthesia,
dysphagia, dysphonia, as well as nerve damage and neurovascular complaints.
BRIEF OPERATIVE COURSE:* Patient was met and greeted in preoperative holding. *
Patient had opportunity to ask all questions, all questions were answered. *
Patient was brought to the operating room.* Patient underwent general
anesthesia.* Timeout was performed.* Next, a longitudinal incision was made on
the left side of the neck.* We used a standard Smith Robinson approach, we
encountered a huge anterior osteophyte.* Using C-arm, we took down the anterior osteophytes* *
at C2, C3 and C4.* We palpated to make sure it was nice and flush.* Once it
was, we got C-arm to confirm that we had removed the anterior osteophyte and
it showed that we had removed with a significant amount of bony spurs.* Next,
we irrigated.* We placed bone wax to help with bleeding as well as help with
recurrent formation.* Once we were happy with that, we placed a drain exiting
the skin and we closed the fascia as well as the platysma with 2-0 Vicryl, 3-0
Monocryl.* I was present and participated in the entire case.