Wiki Spine coding for staged procedure

[Orthosports]

I am new at spine coding and am wondering if someone could help me code this procedure. I am not sure if you would need the entire operative report or if the list of procedures would suffice. This is a staged procedure and has knocked me off my socks.

If anyone has anytime to work with me via this website coding some surgeries until I get a grasp on it would be greatly appreciated.

Thank you so much!!
Denise

STAGE ONE

PREOPERATIVE DIAGNOSIS:
1. Right L2-L3 foraminal stenosis, with right L2-L3 radiculopathy.
2. Lumbar degenerative scoliosis, with advanced right L2-L3
degenerative disc disease and an asymmetric disk collapse on the
right.

POSTOPERATIVE DIAGNOSIS:
1. Right L2-L3 foraminal stenosis, with right L2-L3 radiculopathy.
2. Lumbar degenerative scoliosis, with advanced right L2-L3
degenerative disc disease and an asymmetric disk collapse on the
right.

PROCEDURE PERFORMED: This is a 2-stage procedure, stage 1 of 2.
1. Anterior interbody fusion through a right lateral approach, L2-L3.
2. Placement of prosthetic interbody device, Choice Spine dolphin
cage, L2-L3, size 45 mm x 17 mm x 6-degree lordotic.
3. Use of bone graft substitute, Vitoss, mixed with cancellous chips.
4. Use of bone marrow aspirate through a separate incision.




STAGE TWO
PREOPERATIVE DIAGNOSES:
1. Right L2-L3 foraminal stenosis, severe with right L2 and L3
radiculopathy.
2. Lumbar degenerative scoliosis with asymmetric disk collapse, right
L2-L3, and severe degenerative changes.

POSTOPERATIVE DIAGNOSES:
1. Right L2-L3 foraminal and lateral recess stenosis with right L2
and L3 radiculopathy.
2. Lumbar degenerative scoliosis with severe degenerative disc
disease at L2-L3 and right L2-L3 severe disc collapse.

PROCEDURE PERFORMED: This is a 2-stage procedure, stage 2 of 2:
1. Posterior lumbar fusion L2-L3.
2. Posterior nonsegmental instrumentation pedicle screws, Stryker
Xia, bilateral L2-L3, size 4.5 mm x 45 mm at both levels.
3. Use of bone graft substitute Vitoss and cancellous chips.
4. Right-sided foraminotomy and facetectomy, L2-L3.

 

[avon4117]

Take a specialty course coding through Aapc..they have tons of them!

 

[sfabrico]

I am new at spine coding and am wondering if someone could help me code this procedure. I am not sure if you would need the entire operative report or if the list of procedures would suffice. This is a staged procedure and has knocked me off my socks.

If anyone has anytime to work with me via this website coding some surgeries until I get a grasp on it would be greatly appreciated.

Thank you so much!!
Denise

STAGE ONE

PREOPERATIVE DIAGNOSIS:
1. Right L2-L3 foraminal stenosis, with right L2-L3 radiculopathy.
2. Lumbar degenerative scoliosis, with advanced right L2-L3
degenerative disc disease and an asymmetric disk collapse on the
right.

POSTOPERATIVE DIAGNOSIS:
1. Right L2-L3 foraminal stenosis, with right L2-L3 radiculopathy.
2. Lumbar degenerative scoliosis, with advanced right L2-L3
degenerative disc disease and an asymmetric disk collapse on the
right.

PROCEDURE PERFORMED: This is a 2-stage procedure, stage 1 of 2.
1. Anterior interbody fusion through a right lateral approach, L2-L3.
2. Placement of prosthetic interbody device, Choice Spine dolphin
cage, L2-L3, size 45 mm x 17 mm x 6-degree lordotic.
3. Use of bone graft substitute, Vitoss, mixed with cancellous chips.
4. Use of bone marrow aspirate through a separate incision.




STAGE TWO
PREOPERATIVE DIAGNOSES:
1. Right L2-L3 foraminal stenosis, severe with right L2 and L3
radiculopathy.
2. Lumbar degenerative scoliosis with asymmetric disk collapse, right
L2-L3, and severe degenerative changes.

POSTOPERATIVE DIAGNOSES:
1. Right L2-L3 foraminal and lateral recess stenosis with right L2
and L3 radiculopathy.
2. Lumbar degenerative scoliosis with severe degenerative disc
disease at L2-L3 and right L2-L3 severe disc collapse.

PROCEDURE PERFORMED: This is a 2-stage procedure, stage 2 of 2:
1. Posterior lumbar fusion L2-L3.
2. Posterior nonsegmental instrumentation pedicle screws, Stryker
Xia, bilateral L2-L3, size 4.5 mm x 45 mm at both levels.
3. Use of bone graft substitute Vitoss and cancellous chips.
4. Right-sided foraminotomy and facetectomy, L2-L3.

Was this a co-surgeon case? Usually these types are, also can you put up the op note?

Try checking out 'the business of spine' it's a great company, full of references. They send monthly emails ect...they come out on site and are really nice. We deal with them a lot.

Also, try Medtronic. They have a Spine line. we deal with them a lot too.

 

[Orthosports]

Samantha Fabrico, CPC

Samantha,

Thank you for your help!!!

Here is the opnote for BG:

STAGE ONE

POSTOPERATIVE DIAGNOSES:
1. Spondylolisthesis, L2-L3, with severe spinal stenosis.
2. Spondylolisthesis, L3-L4 with severe spinal stenosis.
3. Progressive motor deficit, right lower extremity.

PROCEDURE PERFORMED: This is a 2-stage procedure, stage 1 of 2.
1. Anterior interbody fusion through a right-sided approach, L2-L3
and L3-L4.
2. Placement of prosthetic interbody device, Dolphin cage; 6 degrees
and 9 x 45 x 17 mm at L2-L3, and 6 degrees and 9 x 50 x 17 mm at
L3-L4.
3. Use of bone graft substitute, Vitoss, and cancellous chips.
4. Use of bone marrow aspirate through a separate incision.


DESCRIPTION OF PROCEDURES: The patient was taken to the operating
room on 07/14/15 and administered general endotracheal tube anesthesia
without any incident. After administration of anesthesia, the patient
was given 1 g IV Ancef as prophylaxis against perioperative infection.
Antibiotics were continued for an additional 24 hours postoperatively
for continued prophylaxis. TED stockings and Venodyne boots were
placed on bilateral lower extremities as prophylaxis against
perioperative DVTs. The patient was then placed with the right side
up in the decubitus position on the C-max table. An axillary roll was
placed beneath the left axilla, and the right side was prepped and
draped in the usual sterile fashion.

A single transverse incision was made just over the center of the L3
vertebral body using a template and measuring approximately 33 mm.
The skin was injected with 10 mL of 0.25% bupivacaine with
epinephrine. Dissection was carried down to the fascia over the
external oblique using Bovie cauterization. Through a separate
fascial incision, a Jamshidi needle was placed into the iliac crest
and 10 mL of bone marrow aspirate was obtained, mixed with Vitoss and
cancellous chips, and reserved for later use. Then, the fascia over
the external oblique was incised in line with the skin incision using
Bovie cauterization. Blunt dissection was carried down through the 3
muscle layers, gaining access to the retroperitoneal space. A series
of dilators were then placed through the retroperitoneal space,
docking on to the psoas muscle, followed by a fixed tube. The fixed
tube was then fastened securely to the operative table and a lateral
fluoroscopic image was obtained to confirm proper operative levels.
Next, under direct visualization, the psoas muscle was split in line
with the muscle fibers using Bovie cauterization. A series of
retractors was then placed, retracting the muscle fibers, giving
excellent visualization of the disk space between L2 and L3. A
complete and thorough diskectomy was then performed using a series of
pituitary rongeurs, curettes, and Kerrison rongeurs. A 17 mm implant
size 9 x 45 mm, 6-degree lordotic was then chosen and packed with the
bone marrow aspirate, Vitoss, cancellous chips mixture. This was
placed into the vertebral space between L2 and L3. Proper position
was confirmed with an AP and lateral fluoroscopic image.

Next, the tube was then moved inferiorly and the L3-L4 level was
approached. Again, a complete and thorough diskectomy was performed
using a series of pituitary rongeurs, curettes, and Kerrison rongeurs.
A second interbody cage size 9 x 15 x 17 mm, 6-degree lordotic was
packed with the bone graft mixture and placed into the disk space in
preparation for fusion. Proper position was then again confirmed with
an AP and a lateral fluoroscopic image.



STAGE TWO
Giargiari,Barbara

POSTOPERATIVE DIAGNOSES:
1. Spondylolisthesis at L2-L3 with severe spinal stenosis.
2. Spondylolisthesis, L3-L4 with severe spinal stenosis.
3. Progressive motor deficits, right lower extremity. Neurogenic
claudication.

PROCEDURES PERFORMED: This is a 2-stage procedure, stage 2 of 2.
1. Posterior L2-L3, L3-L4 decompressive laminectomies.
2. Posterolateral L2-L3, L3-L4 fusion.
3. Bilateral Orthofix pedicle screw instrumentation with 6.5 x 45 mm
screws bilaterally at L4 and 6.5 x 50 mm screws bilaterally at L3 and
L2. Right-sided titanium rod 70 mm, left-sided titanium rod, 65 mm.
4. Use of local autogenous graft combined with Vitoss graft
substitute.
5. Use of intraoperative Stryker 3D navigation system.


A midline incision was then made overlying the L2-L3 and L3-L4
interspace incision and was then taken down through subcutaneous
tissue down to the level of the dorsal lumbar fascia where sharp
bilateral subperiosteal dissection was completed. Intraoperative
fluoroscopy was utilized to confirm the appropriate levels of
dissection. Deep retractors were placed.
The L1-L2 facet capsule was exposed and preserved at all times. The
L2-L3 and the L3-L4 facet capsules were removed and the articular
cartilage of the joints were denuded. The associated transverse
processes were also cleared off of soft tissues and prepared for later
grafting.

The inferior aspect of the L4 lamina was then released off its
ligamentum flavum attachments and a complete laminectomy performed
through the superior aspect of L2 followed by bilateral lateral recess
decompression and foraminotomies for the exiting L2, L3, and L4 nerve
roots were all well decompressed. The nerve roots were easily mobile
to 1 cm tear at the end of the procedure as was the dural sac. The
nerve roots had good glide. We were able to place a Woodson through
the associated foramina without any resistance.

The local laminectomy bone was then morcellized and prepared for later
grafting. The instrumentation part of the procedure was then
performed. The navigation system by Stryker was calibrated and
tracking device was placed in the posterior superior iliac spine.
Then, using the instrumentation, each pedicle starting point was
identified, followed by an awl, pedicle finder, a ball tip and then
K-wire cannulation into the vertebral body. Following care were
insertion position was confirmed in the AP and lateral fluoroscopic
planes. Then, we proceeded with tapping and insertion of a 6.5 mm x
45 mm screw bilaterally at L4 and 6.5 x 50 mm screws bilaterally at L3
and L2. Each screw had excellent purchase and a final position was
confirmed with AP and lateral plane fluoroscopic images. The
transverse processes were then decorticated and bone graft placed
bilaterally. Appropriate length lordotic rods were attached to the
screws followed by final set screw fixation. The wounds were then
copiously irrigated and closed. One gram of vancomycin powder was
used intraoperatively in the wound given her diabetic status and
instrumentation.

The fascial layer was closed with #1 Vicryl sutures in both running
interrupted fashion while the subcutaneous tissue was closed with 2-0
Vicryl sutures, and the skin was closed with a running 3-0 nylon
stitch. The incision for the navigation system was also closed using
2-0 Vicryl subcutaneous and a running 3-0 nylon stitch for the skin.
Prior to the closure, there was no CSF or active bleeding. Hemostasis
was achieved using bipolar cautery and FloSeal. Following closure,
Steri-Strips and sterile dressings were then all applied on top of the
nylon sutures. The patient was then returned to the supine position,
extubated in the operating room and returned to the recovery room in
stable condition having tolerated the procedure well and moving all
extremities.