RebeccaWoodward*
True Blue
Below was coded as 63056 and 63030. There aren't any NCCI edits against these two codes. The carrier has denied 63030 as inclusive into 63056. The surgeon feels strongly that these are separate, billable codes. I would really appreciate any input….Thanks!
PREPROCEDURE DIAGNOSIS: Right L4-5 disk bulge with intra and extraspinal potential nerve root compression.
POSTPROCEDURE DIAGNOSIS: Right L4-5 disk bulge with intra and extraspinal potential nerve root compression with intraspinal subligamentous disk herniation, far lateral disk bulge.
PROCEDURE: Intra and extraspinal approach to right L4-5 disk space with intra and extraspinal diskectomy, decompression of L4 and L5 nerve roots. Minimally invasive approach utilizing Medtronic METRx system.
SPECIAL PROCEDURES: Fluoroscopy for less than 60 minutes, replacement of operative portal and operative microscope for microdissection.
PROCEDURE: The patient was brought to the operating room, intubated in her own bed, and induced under general anesthesia. She was then turned into a prone position on the spine table and positioned according to protocol. Thromboguards had been placed. Her back was prepped and draped in the usual fashion. Fluoroscopy was instituted, and initially on the AP view the right L4-5 facet was localized and cannulated with a spinal needle. Then under the lateral view this was confirmed to be the L4-5 disk space. A paraspinal incision was made, and the Medtronic METRx tubular system was used to dilate an operative portal down to the right L4-5 region. Dissection was carried out both in the interlaminar region but also on the lateral aspect of the facet joint, anticipating both and intra and extraspinal approach. A 26 mm tube was eventually docked on the right-hand side centered over the more medial aspect of the L4-5 disk space. This was confirmed with both AP and lateral fluoroscopic images and was demonstrated to be in excellent position.
The fluoroscopy was removed and operative microscope brought into field. Further soft tissue was reflected off the interlaminar space, which was nicely exposed. A combination of drill and Kerrison rongeurs was used to carry out a hemilaminotomy and foraminotomy, and the lateral ligamentum flavum was resected. An up-angled 2 mm Kerrison was used to alleviate the lateral recess stenosis, taking care to preserve the _______________ aspect of the facet joint given the anticipated far lateral approach as well. This was nicely accomplished. The L5 nerve root was well decompressed with the foraminotomy as well. The L5 nerve root was identified and mobilized gently medially. As we reached the level of the disk space there was a sizeable, almost reducible bulge there. The L5 nerve root and thecal sac were held gently medially with cottonoid patties. The annulus was incised with an 11 blade knife, and a sizable piece of both nucleus polyposis and endplate teased out from underneath the annulus laterally. This was a partially extruded fragment, though it had not completely come through the annulus itself. A routine diskectomy was performed removing all loose and degenerative disk material with a combination of gentle curettage and pituitary rongeurs. Special attention was directed laterally underneath the facet joint, using back-angle Kerrison and pituitary rongeurs to remove as much disk material from there as possible. The L5 nerve root was nicely decompressed. With a long nerve root hook as well as a dental instrument, I could palpate the more lateral annulus underneath the facet joint. It still felt somewhat tight, and I proceeded with the extraspinal approach as anticipated.
The tube was repositioned more laterally, exposing the very lateral aspect of the L4-5 facet. A combination of drill and 1 and 2 mm Kerrison rongeurs as well as the up-angle Kerrison rongeur was used to expose the lateral aspect of the disk space. The L4 nerve root was identified and was noted to almost be medially displaced, certainly much more medial than what we usually see. I was able to gently mobilize it a little more laterally, and there was a very large prominent bulge from the
L4-5 disk space far laterally, which had been displacing the L4 nerve root somewhat medially. This was incised and another piece of endplate and annulus was removed from the far lateral aspect of the disk space with marked relaxation of the L4 nerve root and resumption of its normal more lateral position. The disk space was entered from the far lateral side, and a few other small pieces of disks could be removed.
Attention was then directed back towards medially, and we reexplored there to be sure that we had not pushed anything from lateral to medial, and that was negative.
At this point the L4 and L5 nerve roots were nicely decompressed. The facet joint was left intact. It was noted to be slightly hypermobile, but again left intact. The disk space was irrigated from intraspinal to extraspinal and then reexplored for any further loose pieces of disk, and this was negative as well. Bony edges were curetted until smooth and waxed with bone wax. Valsalva was performed. There was no evidence of CSF leak. Surgicel was left overlying the dura where it approximated bone, and then 1 mL of 40 mg/mL Depo-Medrol was introduced into the epidural and extraspinal _______________ over the nerve roots. As the tubular retractor was slowly withdrawn, hemostasis was achieved. The wound was subsequently closed with Vicryl for fascial and subcutaneous closure and skin staples for skin apposition.
PREPROCEDURE DIAGNOSIS: Right L4-5 disk bulge with intra and extraspinal potential nerve root compression.
POSTPROCEDURE DIAGNOSIS: Right L4-5 disk bulge with intra and extraspinal potential nerve root compression with intraspinal subligamentous disk herniation, far lateral disk bulge.
PROCEDURE: Intra and extraspinal approach to right L4-5 disk space with intra and extraspinal diskectomy, decompression of L4 and L5 nerve roots. Minimally invasive approach utilizing Medtronic METRx system.
SPECIAL PROCEDURES: Fluoroscopy for less than 60 minutes, replacement of operative portal and operative microscope for microdissection.
PROCEDURE: The patient was brought to the operating room, intubated in her own bed, and induced under general anesthesia. She was then turned into a prone position on the spine table and positioned according to protocol. Thromboguards had been placed. Her back was prepped and draped in the usual fashion. Fluoroscopy was instituted, and initially on the AP view the right L4-5 facet was localized and cannulated with a spinal needle. Then under the lateral view this was confirmed to be the L4-5 disk space. A paraspinal incision was made, and the Medtronic METRx tubular system was used to dilate an operative portal down to the right L4-5 region. Dissection was carried out both in the interlaminar region but also on the lateral aspect of the facet joint, anticipating both and intra and extraspinal approach. A 26 mm tube was eventually docked on the right-hand side centered over the more medial aspect of the L4-5 disk space. This was confirmed with both AP and lateral fluoroscopic images and was demonstrated to be in excellent position.
The fluoroscopy was removed and operative microscope brought into field. Further soft tissue was reflected off the interlaminar space, which was nicely exposed. A combination of drill and Kerrison rongeurs was used to carry out a hemilaminotomy and foraminotomy, and the lateral ligamentum flavum was resected. An up-angled 2 mm Kerrison was used to alleviate the lateral recess stenosis, taking care to preserve the _______________ aspect of the facet joint given the anticipated far lateral approach as well. This was nicely accomplished. The L5 nerve root was well decompressed with the foraminotomy as well. The L5 nerve root was identified and mobilized gently medially. As we reached the level of the disk space there was a sizeable, almost reducible bulge there. The L5 nerve root and thecal sac were held gently medially with cottonoid patties. The annulus was incised with an 11 blade knife, and a sizable piece of both nucleus polyposis and endplate teased out from underneath the annulus laterally. This was a partially extruded fragment, though it had not completely come through the annulus itself. A routine diskectomy was performed removing all loose and degenerative disk material with a combination of gentle curettage and pituitary rongeurs. Special attention was directed laterally underneath the facet joint, using back-angle Kerrison and pituitary rongeurs to remove as much disk material from there as possible. The L5 nerve root was nicely decompressed. With a long nerve root hook as well as a dental instrument, I could palpate the more lateral annulus underneath the facet joint. It still felt somewhat tight, and I proceeded with the extraspinal approach as anticipated.
The tube was repositioned more laterally, exposing the very lateral aspect of the L4-5 facet. A combination of drill and 1 and 2 mm Kerrison rongeurs as well as the up-angle Kerrison rongeur was used to expose the lateral aspect of the disk space. The L4 nerve root was identified and was noted to almost be medially displaced, certainly much more medial than what we usually see. I was able to gently mobilize it a little more laterally, and there was a very large prominent bulge from the
L4-5 disk space far laterally, which had been displacing the L4 nerve root somewhat medially. This was incised and another piece of endplate and annulus was removed from the far lateral aspect of the disk space with marked relaxation of the L4 nerve root and resumption of its normal more lateral position. The disk space was entered from the far lateral side, and a few other small pieces of disks could be removed.
Attention was then directed back towards medially, and we reexplored there to be sure that we had not pushed anything from lateral to medial, and that was negative.
At this point the L4 and L5 nerve roots were nicely decompressed. The facet joint was left intact. It was noted to be slightly hypermobile, but again left intact. The disk space was irrigated from intraspinal to extraspinal and then reexplored for any further loose pieces of disk, and this was negative as well. Bony edges were curetted until smooth and waxed with bone wax. Valsalva was performed. There was no evidence of CSF leak. Surgicel was left overlying the dura where it approximated bone, and then 1 mL of 40 mg/mL Depo-Medrol was introduced into the epidural and extraspinal _______________ over the nerve roots. As the tubular retractor was slowly withdrawn, hemostasis was achieved. The wound was subsequently closed with Vicryl for fascial and subcutaneous closure and skin staples for skin apposition.
