daniellebailey2244@gmail.com
Networker
Can someone please help me with this spinal surgery, I feel like I start to go down a rabbit hole with the arthrodesis and osteotomy codes: With the procedure below, I can up with 22551, 22552(2), 20937 & 22853(3). I am unable to capture allograft codes for this facility as the procedure codes must be applicable for the AS Modifier. Where I get confused is adding in the osteotomy codes. With this being anterior cervical 22220 would be where I go first, however this code bundles with 22551? Can anyone help me with clarification. Thank you so much in advance for your help 
Sorry Have to post the procedure in two notes
Operative Note
Pre-op diagnosis:
Cervical spondylitic myelopathy C3-C6 with spinal cord compression
Post-op diagnosis:
Same
Procedure done:
C3-6 anterior cervical discectomy and fusion
Procedure:
Patient was identified in the preoperative area informed consent was obtained and verified marked site was marked and he was brought back to the operating room for surgery. General anesthesia was induced she was placed supine on the bed sequential compression devices were utilized in lower extremities for DVT prophylaxis. A bump was placed between the shoulder blades elevate the thorax the neck was placed in a slightly extended position the arms were tucked at the patient's side and padded. Tape was applied to the shoulders and a longitudinal traction was applied. A grounding pad was carefully positioned in the thigh and a strap was positioned on the legs to hold her in position. We prepped and draped in usual sterile fashion and a timeout was performed and all were in agreement.
Cervical approach,
A 10 blade was used to perform a 2.5 inch incision transverse on the right side parallel to Langer's lines. The incision was carried down to the subcutaneous tissue identified the platysma muscle. The subsequently incised using Bovie electrocautery knife. The medial border the sternocleidomastoid was identified and palpated. We then developed the interval between the carotid sheath and the esophagus and the anterior aspect of the cervical spine was felt. We then elevated the prevertebral fascia and identified the longus colli muscles. We then went up and down the carotid sheath and sternocleidomastoid to get a wide dissection and exposure from C3-6. The disc space of C3-4 was identified and a spinal needle was placed a crosstable lateral was obtained to identify the correct level. We used a protect the protected Bovie electrocautery and elevated the longus colli muscles in a subperiosteal fashion from the respective medial borders from C3-6. With the muscles elevated the self-retaining retractors were placed thus providing excellent exposure. At this point a Leica microscope was brought into the surgical field and surgery continued under microscopic vision at this point. A cast bar type self-retaining retractor and the intervertebral body distractors were placed at the C3-4 level.
Anterior cervical osteotomy at C3-4
There was a large bridging syndesmophyte that precluded access to the disc space at the C3-4 level. This went all the way to the uncovertebral joints laterally. It was quite large and precluded typical anterior cervical discectomy and fusion. We used a series of osteotomes and a crosstable lateral to perform an osteotomy through this bridging syndesmophyte essentially through the anterior column of the spine to mobilize the segment and gain access to the disc space. We carried this laterally to the uncovertebral joint doing this both flush with the upper and lower endplate. We then meticulously dissected this off of the anterior longitudinal ligament and annulus anteriorly. We then used a high-speed cutting bur to complete the osteotomy we could then see with placement of cast bar pin retractor that the disc space was now mobile and the normal anterior cervical discectomy and fusion could now proceed.
Anterior cervical discectomy and fusion C3-4
We used a 15 blade to perform an incision to the anterior longitudinal ligament and annulus we used a pituitary rongeur the disc was sequentially removed after a complete discectomy was performed. All disc material as far lateral as the uncovertebral joints was removed and as far posteriorly as the posterior longitudinal ligament. We used a 1 mm Kerrison and Karlin curettes to resect the PLL exposing the dura we distracted the Caspar pins at this point performed bilateral foraminotomies decompressing the C4 nerve roots we completed the medial foraminotomies using #1 and #2 Kerrisons.
Interbody cage placement C3-4, morselized autograft C3-4 and arthrodesis of C3-4
After complete discectomy was done at this level of the inferior portion and superior portion of C3 and C4 were prepared this was employed using a high-speed bur with cutting matchstick head. The morselized autograft was collected with a special attachment to the suction. The bleeding bone surfaces were smoothed out using a bur to provide a surface for arthrodesis at each bony surface. A titanium coated peek cage was selected after sizing the interspace. The cage was sequentially filled with allograft and morselized autograft and tamped into place. There was excellent position of the cage the cage was 6 mm high graft.
Anterior cervical osteotomy at C4-5
There was a large bridging syndesmophyte that precluded access to the disc space at the C4-5 level. This went all the way to the uncovertebral joints laterally. It was quite large and precluded typical anterior cervical discectomy and fusion. We used a series of osteotomes and a crosstable lateral to perform an osteotomy through this bridging syndesmophyte essentially through the anterior column of the spine to mobilize the segment and gain access to the disc space. We carried this laterally to the uncovertebral joint doing this both flush with the upper and lower endplate. We then meticulously dissected this off of the anterior longitudinal ligament and annulus anteriorly. We then used a high-speed cutting bur to complete the osteotomy we could then see with placement of cast bar pin retractor that the disc space was now mobile and the normal anterior cervical discectomy and fusion could now proceed.
Anterior cervical discectomy and fusion C4-5
We used a 15 blade to perform an incision to the anterior longitudinal ligament and annulus we used a pituitary rongeur the disc was sequentially removed after a complete discectomy was performed. All disc material as far lateral as the uncovertebral joints was removed and as far posteriorly as the posterior longitudinal ligament. We used a 1 mm Kerrison and Karlin curettes to resect the PLL exposing the dura we distracted the Caspar pins at this point performed bilateral foraminotomies decompressing the C5 nerve roots we completed the medial foraminotomies using #1 and #2 Kerrisons.
Interbody cage placement C4-5, morselized autograft C4-5 and arthrodesis of C4-5
After complete discectomy was done at this level of the inferior portion and superior portion of C4 and C5 were prepared this was employed using a high-speed bur with cutting matchstick head. The morselized autograft was collected with a special attachment to the suction. The bleeding bone surfaces were smoothed out using a bur to provide a surface for arthrodesis at each bony surface. A titanium coated peek cage was selected after sizing the interspace. The cage was sequentially filled with allograft and morselized autograft and tamped into place. There was excellent position of the cage the cage was 7 mm high graft.
Sorry Have to post the procedure in two notesOperative Note
Pre-op diagnosis:
Cervical spondylitic myelopathy C3-C6 with spinal cord compression
Post-op diagnosis:
Same
Procedure done:
C3-6 anterior cervical discectomy and fusion
Procedure:
Patient was identified in the preoperative area informed consent was obtained and verified marked site was marked and he was brought back to the operating room for surgery. General anesthesia was induced she was placed supine on the bed sequential compression devices were utilized in lower extremities for DVT prophylaxis. A bump was placed between the shoulder blades elevate the thorax the neck was placed in a slightly extended position the arms were tucked at the patient's side and padded. Tape was applied to the shoulders and a longitudinal traction was applied. A grounding pad was carefully positioned in the thigh and a strap was positioned on the legs to hold her in position. We prepped and draped in usual sterile fashion and a timeout was performed and all were in agreement.
Cervical approach,
A 10 blade was used to perform a 2.5 inch incision transverse on the right side parallel to Langer's lines. The incision was carried down to the subcutaneous tissue identified the platysma muscle. The subsequently incised using Bovie electrocautery knife. The medial border the sternocleidomastoid was identified and palpated. We then developed the interval between the carotid sheath and the esophagus and the anterior aspect of the cervical spine was felt. We then elevated the prevertebral fascia and identified the longus colli muscles. We then went up and down the carotid sheath and sternocleidomastoid to get a wide dissection and exposure from C3-6. The disc space of C3-4 was identified and a spinal needle was placed a crosstable lateral was obtained to identify the correct level. We used a protect the protected Bovie electrocautery and elevated the longus colli muscles in a subperiosteal fashion from the respective medial borders from C3-6. With the muscles elevated the self-retaining retractors were placed thus providing excellent exposure. At this point a Leica microscope was brought into the surgical field and surgery continued under microscopic vision at this point. A cast bar type self-retaining retractor and the intervertebral body distractors were placed at the C3-4 level.
Anterior cervical osteotomy at C3-4
There was a large bridging syndesmophyte that precluded access to the disc space at the C3-4 level. This went all the way to the uncovertebral joints laterally. It was quite large and precluded typical anterior cervical discectomy and fusion. We used a series of osteotomes and a crosstable lateral to perform an osteotomy through this bridging syndesmophyte essentially through the anterior column of the spine to mobilize the segment and gain access to the disc space. We carried this laterally to the uncovertebral joint doing this both flush with the upper and lower endplate. We then meticulously dissected this off of the anterior longitudinal ligament and annulus anteriorly. We then used a high-speed cutting bur to complete the osteotomy we could then see with placement of cast bar pin retractor that the disc space was now mobile and the normal anterior cervical discectomy and fusion could now proceed.
Anterior cervical discectomy and fusion C3-4
We used a 15 blade to perform an incision to the anterior longitudinal ligament and annulus we used a pituitary rongeur the disc was sequentially removed after a complete discectomy was performed. All disc material as far lateral as the uncovertebral joints was removed and as far posteriorly as the posterior longitudinal ligament. We used a 1 mm Kerrison and Karlin curettes to resect the PLL exposing the dura we distracted the Caspar pins at this point performed bilateral foraminotomies decompressing the C4 nerve roots we completed the medial foraminotomies using #1 and #2 Kerrisons.
Interbody cage placement C3-4, morselized autograft C3-4 and arthrodesis of C3-4
After complete discectomy was done at this level of the inferior portion and superior portion of C3 and C4 were prepared this was employed using a high-speed bur with cutting matchstick head. The morselized autograft was collected with a special attachment to the suction. The bleeding bone surfaces were smoothed out using a bur to provide a surface for arthrodesis at each bony surface. A titanium coated peek cage was selected after sizing the interspace. The cage was sequentially filled with allograft and morselized autograft and tamped into place. There was excellent position of the cage the cage was 6 mm high graft.
Anterior cervical osteotomy at C4-5
There was a large bridging syndesmophyte that precluded access to the disc space at the C4-5 level. This went all the way to the uncovertebral joints laterally. It was quite large and precluded typical anterior cervical discectomy and fusion. We used a series of osteotomes and a crosstable lateral to perform an osteotomy through this bridging syndesmophyte essentially through the anterior column of the spine to mobilize the segment and gain access to the disc space. We carried this laterally to the uncovertebral joint doing this both flush with the upper and lower endplate. We then meticulously dissected this off of the anterior longitudinal ligament and annulus anteriorly. We then used a high-speed cutting bur to complete the osteotomy we could then see with placement of cast bar pin retractor that the disc space was now mobile and the normal anterior cervical discectomy and fusion could now proceed.
Anterior cervical discectomy and fusion C4-5
We used a 15 blade to perform an incision to the anterior longitudinal ligament and annulus we used a pituitary rongeur the disc was sequentially removed after a complete discectomy was performed. All disc material as far lateral as the uncovertebral joints was removed and as far posteriorly as the posterior longitudinal ligament. We used a 1 mm Kerrison and Karlin curettes to resect the PLL exposing the dura we distracted the Caspar pins at this point performed bilateral foraminotomies decompressing the C5 nerve roots we completed the medial foraminotomies using #1 and #2 Kerrisons.
Interbody cage placement C4-5, morselized autograft C4-5 and arthrodesis of C4-5
After complete discectomy was done at this level of the inferior portion and superior portion of C4 and C5 were prepared this was employed using a high-speed bur with cutting matchstick head. The morselized autograft was collected with a special attachment to the suction. The bleeding bone surfaces were smoothed out using a bur to provide a surface for arthrodesis at each bony surface. A titanium coated peek cage was selected after sizing the interspace. The cage was sequentially filled with allograft and morselized autograft and tamped into place. There was excellent position of the cage the cage was 7 mm high graft.