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
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