Wiki Spine coding

todd5400

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I would appreciate some other opinions please

Patient had instrumentation surgery the day prior.

Preop diag: left L5 radiculopthy, right L3 pedicle screw placement

Procedure: Removal and replacement of right L3 pedicle screw. Resection of left L5 pedicle decompression of L5 nerve root.

Description: The previously made incisino was reopened. The right sided L3 pedicle screw was removed. A new screw was placed. It was probed to insure good bony purchase. The titanium rod was replaced. Attention focused at the L5-S1 level on the left. The entire top of the facet and pedicle was removed to fully decompress the nerve all the way out into the soft tissue. Once this was accomplished wound was irrigated and closed.

Thanks
 
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