Wiki Spine - code this Op Report


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Could someone please help me code this Op Report? At our office we need a 3rd opinion. We just need to know if you would code this Report with a Refusion Posterior Column or a Refusion Anterior Column.

The patient was taken to the operating room and given general anesthetic. She was turned in the supine position. The cervical spine was placed in lordosis.

The skin was cleaned and draped in the usal manner. An oblique incision was made over the right anterior iliac crest. The skin and subcutaneous tissue, including the platysma were incised in the same line. The interval between the sternocleidomastoid and tract of esophagus was divided down to the anterior cervical spine to explore the plates at C3-4 and C5-6.

Using the removal instruments, four locking screws were removed from the plate at C3-4 and four locking screws were removed from the plate at C5-6. Once the plates were removed the underlying fusion was evaluated for evidence of union. There was evidence of gross motion at the C5-C6 tha was consistent with a pseudoarthrosis. There was only a very thin shell of the bine at the interspace.

There was evidence of overlying syndesmophytes overgrowing in the C4-5 interspace. Overlying syndesmophytes were removed. A #15 blade was used to incise the margin of the disk at the C4-5 level. Above and below, the disk was elevated from its endplates and discectomy done all the way back th the posterior annulus.

Herniated disk material was removed. Posterior syndesmophytes were trimmed. Partial corpectomies were done of the lower aspect of C4 and the upper aspects of C5 to give pilot bone bleeding surfaces. Generous firm decompressions were done and bilateral uncovertebral joint resections were carried out. This disk was distracted and size with appropriate size graft.

On account of the bone being demonstrably soft, it was decided not to use autograft bone but use allograft bone.

The fusion at C3-4 was similary examined and there was no evidence of fail of continuity and no evidence pseudoarthrosis and fusion at C3-4 was established.

At the C5-C6 level, the pseudoarthrosis was entered and completely excised all the way back to the posterior annulus. Posterior syndesmophytes formation was noted. These were resected. Partial corpectomies were done at the lower aspect of C5 and the upper aspect of C6, such that pilot bone bleeding surfaces were established. The area was irrigated with antibiotic saline. The space was distracted.

The space was sized for the appropriate sized graft. Care was taken to perform generous round of decompressions with uncovertebral joint resection.

A size 10 cortical cancellous allograft construct was used at C5-6 and size 8 at C4-5. Both were insereted and recessed to a distance of 1 to 2 mm from the anterior surface of the bone.

This was now re-instrumented using a Frontier infuse cervical plate. A 4 to 5 mm plate was affixed to the spine and 4 locking screws measuring 4.3 x 12 mm applied at C4, C5 and C6 to create a stable construct. The wound was irrigated and a drain was placed. The patient was transferred to the PACU.

Should we use ICD-9 vol 3 procedure code:
81.32 or 81.33 ?

Thank you. Robin from Houston, Texas
Not my area of expertise

Not my area of expertise, but you might more expert advice if you posted this in the Orthopedics Forum.

Hope that helps.

F Tessa Bartels, CPC, CEMC
I am not familiar with hospital codes, my expertise is Neurosurgery CPT coding, but from reading the OR, this is refusion anterior, patient was placed supine and all the work done looks like it is describing a cervical ACDF, (anterior), not posterior fusion.
Oh I was just wondering why they would make the incision over the iliac crest for a cervical fusion istead of making the incision in the cervical area.
Gottcha - I can give you your answer. As you know a fusion is the "mending" of collapsed vertebra -- the reason that you are seeing an incision being made over the iliac crest is because the physician is obtaining bone from the hip bone itself (autograft). According to a few docs bone from the iliac crest is top of the line. So you may have a situation where the dictation is not as good as it should be with the doc indicating that after removing a bone piece he/she proceeded to the either a pos/ant approach of the patients neck and placed the bone through a sep incision. I have never seen them go that far down to get up. I have always seen this procedure done through the neck.
Hope that makes some sense. I have never really tried to explain it before.