shobaram
Contributor
Can some one please help with this coding,
Pre and post dx: severe lumbar stenosis, gait disorder, severe lumbar pain, failed conservative measures, and severe facet arthropathy
Procedure performed:1. OPen L2-L3 and L3-L4 TLIF combined with posterior fusion with local autograft and allograft.
2. placement of titanium cage at the L2-3 level anteriorly and 2 PEEK cages at the L3-4 level bialterally, use of pedicle screw instrumentation bilaterally at L2,L3 and L4.
3. L2-3 and L3-4 bilateraly laminectomy and Gill procedure at L2-3 and L3-4 beyond that which was necessary for the TLIF,use of nerve monitoring, use of interaoperative fluroscopy.
Findings: chronic and acute herniated disk at the midline at L2-3 severe bilateral facet arthropathy with facet arthropathy causing far lateral neural foraminal stenosis.
Technique: This pt who is progressed to an inability to walk much more than 100 feet or so at a time. He has severe back pain, neurogenic claudication radiating lower extremity pain, and very severe stenosis at L2-3 and L3-4 on the MRI. The pt does have autofushion at L4-L5 and therefore a different doctor may use a different numbering system.
Description of the procedure: The pt was taken to the operating room, induced and intubated without difficulty, placed in the prone position. A posterior aspect of the back was prepped and draped in sterile fashion. A linear incision was made and dissection was carried down to the bony anatomy in the subperiosteal fashion. Self retaining retractors were applied. Dissection was carried all the way out to the transverse processes bilaterally. The facets were quite huge. After the retractors were in place and the bony anatomy was exposed. Using a high speed drill bit and various size kerrison rongeurs, a radical laminectomy was fashioned at L2-3 and L3-4. This dissection was carried out laterally to fashion a Gill laminectomy at each level. The superior facet of L3 and the superior facet of L4 bilaterally ascended quite high and both on MRI and intraoperatively appeared to cause severe neural compression bilaterally in the foramen and quite laterally in the foramen and extra foraminally. This was the reasoning behind doing an extensive lateral dissection through the facet bilaterally at each level. A high speed drill bit was used for the majority of this dissection. Much of the local autograft was collected for lateral use. The lamina spinous process was also removed with rongerurs. The underlying ligamentum flavum was identified. Much of it was quite calcified or ossified and adherent to the dura. A great deal of care was needed to dissect the ossified ligament off the dura without causing a CSF leak. At no time did an incidental durotomy occur. After the lamina was well decompressed, dissection was then continued to the facets as described above. The nerve roots were identified at each level. The facets were completely removed. After all the decompression was completed, the disk space on the left side at L3-4 was opened with a knife and various rongeurs. A radical diskectomy was fashioned on the left side at L3-4, an appropriate sized PEEK cage was placed into the intervertebral space after being packed with local autograft and allograft. A curved cage was used at the L2-3 level and passed down to the very anterior aspect of the disk space, completing the TLIF. There was noted a very adherent chronic and acute disk herniation noted at the midline L2-3. A great deal of time was spent trying to decompress this and teased off the dura, but it was quite adherent. Such a good decompression was had posteriorly that a ramnant of the disk was left behind given its medial location. After this was completed, pedicle screws were placed in the left side pedicles at L2,L3 and L4 by drilling and tapping first. Good trajectories were noted on the X ray. Attention was then directed to the right side where a further diskectomy was fashioned on the right side of L3-4. Again, various sized disk shavers and curettes were used to further the diskectomy. After this was completed, again a PEEK cage was placed into the intervertebral space and confirmed on fluoroscopy. Again, this was packed with local autograft and allograft as well as the disk space proper. This appeared to distract the disk space small degree. After this was completed, the pedicle screws were then placed into the L2,L3, and L4 levels on the right side as well. The pedicles were compressed and appropriately size rods were placed and then the set screws were final tightened. After this was completed, the wound was irrigated with saline irrigant. The posterior elements were decorticated with a high speed drill bit. A remnant autograft and allograft were used in the posterior location between the transverse processes and between the remaining facet complexes. Anterior and posterior X rays were also obtained and showed good trajectory of the screws. After this was completed, the posterior fusion was completed. The wound was closed in interrupted fashion with Vicryl sutures and staples. A drain was placed subfascially and submuscularly and secured in place with a single suture. Sterile dressing was applied. The pt was taken back to the postanesthesia recovery in stable condition.
is the coding 22633, 63012 - 59(Gill type procedure) , 22853 X 3,20931 and 20936.
Thanks in advance
Pre and post dx: severe lumbar stenosis, gait disorder, severe lumbar pain, failed conservative measures, and severe facet arthropathy
Procedure performed:1. OPen L2-L3 and L3-L4 TLIF combined with posterior fusion with local autograft and allograft.
2. placement of titanium cage at the L2-3 level anteriorly and 2 PEEK cages at the L3-4 level bialterally, use of pedicle screw instrumentation bilaterally at L2,L3 and L4.
3. L2-3 and L3-4 bilateraly laminectomy and Gill procedure at L2-3 and L3-4 beyond that which was necessary for the TLIF,use of nerve monitoring, use of interaoperative fluroscopy.
Findings: chronic and acute herniated disk at the midline at L2-3 severe bilateral facet arthropathy with facet arthropathy causing far lateral neural foraminal stenosis.
Technique: This pt who is progressed to an inability to walk much more than 100 feet or so at a time. He has severe back pain, neurogenic claudication radiating lower extremity pain, and very severe stenosis at L2-3 and L3-4 on the MRI. The pt does have autofushion at L4-L5 and therefore a different doctor may use a different numbering system.
Description of the procedure: The pt was taken to the operating room, induced and intubated without difficulty, placed in the prone position. A posterior aspect of the back was prepped and draped in sterile fashion. A linear incision was made and dissection was carried down to the bony anatomy in the subperiosteal fashion. Self retaining retractors were applied. Dissection was carried all the way out to the transverse processes bilaterally. The facets were quite huge. After the retractors were in place and the bony anatomy was exposed. Using a high speed drill bit and various size kerrison rongeurs, a radical laminectomy was fashioned at L2-3 and L3-4. This dissection was carried out laterally to fashion a Gill laminectomy at each level. The superior facet of L3 and the superior facet of L4 bilaterally ascended quite high and both on MRI and intraoperatively appeared to cause severe neural compression bilaterally in the foramen and quite laterally in the foramen and extra foraminally. This was the reasoning behind doing an extensive lateral dissection through the facet bilaterally at each level. A high speed drill bit was used for the majority of this dissection. Much of the local autograft was collected for lateral use. The lamina spinous process was also removed with rongerurs. The underlying ligamentum flavum was identified. Much of it was quite calcified or ossified and adherent to the dura. A great deal of care was needed to dissect the ossified ligament off the dura without causing a CSF leak. At no time did an incidental durotomy occur. After the lamina was well decompressed, dissection was then continued to the facets as described above. The nerve roots were identified at each level. The facets were completely removed. After all the decompression was completed, the disk space on the left side at L3-4 was opened with a knife and various rongeurs. A radical diskectomy was fashioned on the left side at L3-4, an appropriate sized PEEK cage was placed into the intervertebral space after being packed with local autograft and allograft. A curved cage was used at the L2-3 level and passed down to the very anterior aspect of the disk space, completing the TLIF. There was noted a very adherent chronic and acute disk herniation noted at the midline L2-3. A great deal of time was spent trying to decompress this and teased off the dura, but it was quite adherent. Such a good decompression was had posteriorly that a ramnant of the disk was left behind given its medial location. After this was completed, pedicle screws were placed in the left side pedicles at L2,L3 and L4 by drilling and tapping first. Good trajectories were noted on the X ray. Attention was then directed to the right side where a further diskectomy was fashioned on the right side of L3-4. Again, various sized disk shavers and curettes were used to further the diskectomy. After this was completed, again a PEEK cage was placed into the intervertebral space and confirmed on fluoroscopy. Again, this was packed with local autograft and allograft as well as the disk space proper. This appeared to distract the disk space small degree. After this was completed, the pedicle screws were then placed into the L2,L3, and L4 levels on the right side as well. The pedicles were compressed and appropriately size rods were placed and then the set screws were final tightened. After this was completed, the wound was irrigated with saline irrigant. The posterior elements were decorticated with a high speed drill bit. A remnant autograft and allograft were used in the posterior location between the transverse processes and between the remaining facet complexes. Anterior and posterior X rays were also obtained and showed good trajectory of the screws. After this was completed, the posterior fusion was completed. The wound was closed in interrupted fashion with Vicryl sutures and staples. A drain was placed subfascially and submuscularly and secured in place with a single suture. Sterile dressing was applied. The pt was taken back to the postanesthesia recovery in stable condition.
is the coding 22633, 63012 - 59(Gill type procedure) , 22853 X 3,20931 and 20936.
Thanks in advance
, in your report, I see the following codes: 22633 (L2-L3 combined fusion); 22634 x1 (L3-L4 combined fusion); 22853 x2 (cage at L2-L3 and cage at L3-L4); 22842 (posterior segmental instrumentation at L2-L4); 20930 (morselized allograft); and 20936 (morselized autograft).