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How do I know that I should report 63020 instead of 63045?
OPERATIVE REPORT
SEX: FEMALE
AGE: 63
This payer requires RT and LT Modifier
DATE OF OPERATION: 01/1/20XX
PREOPERATIVE DIAGNOSIS: RIGHT-SIDED C6-C7 RADICULOPATHY FROM FORAMINAL STENOSIS AT C5-6 AND C6-7.
POSTOPERATIVE DIAGNOSIS: RIGHT-SIDED C6-C7 RADICULOPATHY FROM FORAMINAL STENOSIS AT C5-6 AND C6-7.
PROCEDURES: RIGHT-SIDED C5-6 AND C6-7 FORAMINOTOMY.
SURGEON: Deon Thompson, M.D.
ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE.
ESTIMATE BLOOD LOSS: LESS THAN 100 CC.
COMPLICATIONS: NONE.
INDICATIONS: The patient is a middle-aged woman with a history of severe pain radiating along the right arm along the C6 and C7 dermatomal distributions. She had undergone a trial of conservative care without significant improvement and for that reason was referred to neurosurgery for further care. She had an MRI that showed degenerative disc with herniation causing foraminal stenosis at the level of C5-6 and C6-7 that correlated with the patient's symptoms. It was for this reason that I recommended performing foraminotomy in order to decompress the entrapped nerves within the foramen.
The procedure along with its risks, possible benefits and possible complications were explained to the patient to her understanding and her questions were answered to her satisfaction. Surgical and nonsurgical alternatives were discussed and the patient consented to the operation as described.
PROCEDURE: The patient was brought into the operating room and while on the stretcher general anesthesia was induced and she was endotracheally intubated. She was then placed with her head on a Mayfield pinhead holder and transferred to the operating table in a prone position of the Wilson frame. Her head was then secured and slight flexion to the operative table.
Lateral fluoroscopy was utilized to identify the level of the spine for the surgery. It was because of the patient's very short neck as well as the patient's shoulder it was very difficult to visualize the spine below C4. We thus had to use fluoroscopy intraoperatively to corroborate the exact location of the surgery but had to extend the incision cranially to identify C4 spinous process in order to be able to count appropriately the C5-6 and C6-7 levels. Having that been done, the site of the incision from approximately the spinous processes of C4 to that of C1 was identified and marked. The surgical site was then shaved, prepped and draped in usual fashion. A midline incision was then made with a scalpel. Subcutaneous tissues were divided with unipolar cautery. The paravertebral musculature was then reflected away from the spinous process as well as the right-sided lamina at the levels of C4, C5, C6 and C7. The muscle takedown was continuous bilaterally over the facet of C5-6 and C6-7 as to expose the majority of the lateral mass and facet structure where the decompression was to take place. After having done so, a unilateral retractor tube placed. It was
placed to maintain adequate exposure throughout the remaining of the case.
After identifying the C6-7 interspace, we began the foraminotomy by separating the ligamentum flavum upon its bony attachments to the C6 and C7 lamina. A distal lateral laminectomy was then performed with great care not to injure the underlying dura. For this a 1-mm Kerrison was utilized. The laminectomy was extended towards the area under the facet joint, we were immediately able to identify the proximal C7 nerve root within the most medial part of the foramen. The foraminotomy was then completed by carefully drilling away this bilateral mass and facet structure until it was paper thin.
The remaining part of the facetectomy was then performed with the use of the #1 Kerrison rongeur. In doing so, we were able to expose the nerve root from its origin at the thecal sac to just before its exit in the foramen where it was no longer being compressed. The foramen at this point appeared to be adequately decompressed as we were able to introduce a dental tool with great (ease) and without any evidence of the nerve root itself being pinched up. Having completed this foraminotomy, the nerve root was covered with a thin Gelfoam and we turned out our attention to the foraminotomy at C5-6. Similarly, a distal laminectomy was performed and the facetectomy was performed by first drilling with a small air drill and removing the facet with a #1 Kerrison rongeur. Similarly, we were able to perform decompression of the entire nerve root, which could be visualized on exit of the thecal sac until just about its exit from the foramen itself. Upon conclusion, it was ascertained that the nerve root was adequately decompressed. We similarly introduced a dental instrument into the foramen and being able to move them freely we could conclude that the nerve root was adequately decompressed.
Both nerve roots were then covered with a small amount of Depo-Medrol solution and then with Gelfoam. Bleeding from the bone was contained with the use of bone wax and small bleeding from soft tissues was stopped using a bipolar cautery. All retractors were then removed and after leaving a Hemovac in the paravertebral musculature immediately overlying the lamina, we turned our attention to the closure. Muscles were brought back together with 0-Vicryl as was the cervical fascia. Subcutaneous tissues were brought back together with 3-Vicryl and skin edges were brought back together with skin staples.
On conclusion, the incision was cleaned with Betadine and sterile dressing was applied in usual fashion. At this point, the patient was transferred to the stretcher in the supine position where Mayfield pinhead holder was removed, general anesthesia was reversed and she was extubated. Upon extubation, she was sleepy but arousable. She was following simple commands and she was moving all her extremities without any evidence of weakness. Her right arm was weak more so biceps and triceps and she had full use of the arm in the recovery room.
The patient tolerated the procedure well and there were no intraoperative complications. At this point, the patient was transferred to the recovery room in stable condition for further monitoring.
Deon Thompson, M.D.
Electronically signed by DEON THOMPSON, MD 1/1/20XX
SEX: FEMALE
AGE: 63
This payer requires RT and LT Modifier
DATE OF OPERATION: 01/1/20XX
PREOPERATIVE DIAGNOSIS: RIGHT-SIDED C6-C7 RADICULOPATHY FROM FORAMINAL STENOSIS AT C5-6 AND C6-7.
POSTOPERATIVE DIAGNOSIS: RIGHT-SIDED C6-C7 RADICULOPATHY FROM FORAMINAL STENOSIS AT C5-6 AND C6-7.
PROCEDURES: RIGHT-SIDED C5-6 AND C6-7 FORAMINOTOMY.
SURGEON: Deon Thompson, M.D.
ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE.
ESTIMATE BLOOD LOSS: LESS THAN 100 CC.
COMPLICATIONS: NONE.
INDICATIONS: The patient is a middle-aged woman with a history of severe pain radiating along the right arm along the C6 and C7 dermatomal distributions. She had undergone a trial of conservative care without significant improvement and for that reason was referred to neurosurgery for further care. She had an MRI that showed degenerative disc with herniation causing foraminal stenosis at the level of C5-6 and C6-7 that correlated with the patient's symptoms. It was for this reason that I recommended performing foraminotomy in order to decompress the entrapped nerves within the foramen.
The procedure along with its risks, possible benefits and possible complications were explained to the patient to her understanding and her questions were answered to her satisfaction. Surgical and nonsurgical alternatives were discussed and the patient consented to the operation as described.
PROCEDURE: The patient was brought into the operating room and while on the stretcher general anesthesia was induced and she was endotracheally intubated. She was then placed with her head on a Mayfield pinhead holder and transferred to the operating table in a prone position of the Wilson frame. Her head was then secured and slight flexion to the operative table.
Lateral fluoroscopy was utilized to identify the level of the spine for the surgery. It was because of the patient's very short neck as well as the patient's shoulder it was very difficult to visualize the spine below C4. We thus had to use fluoroscopy intraoperatively to corroborate the exact location of the surgery but had to extend the incision cranially to identify C4 spinous process in order to be able to count appropriately the C5-6 and C6-7 levels. Having that been done, the site of the incision from approximately the spinous processes of C4 to that of C1 was identified and marked. The surgical site was then shaved, prepped and draped in usual fashion. A midline incision was then made with a scalpel. Subcutaneous tissues were divided with unipolar cautery. The paravertebral musculature was then reflected away from the spinous process as well as the right-sided lamina at the levels of C4, C5, C6 and C7. The muscle takedown was continuous bilaterally over the facet of C5-6 and C6-7 as to expose the majority of the lateral mass and facet structure where the decompression was to take place. After having done so, a unilateral retractor tube placed. It was
placed to maintain adequate exposure throughout the remaining of the case.
After identifying the C6-7 interspace, we began the foraminotomy by separating the ligamentum flavum upon its bony attachments to the C6 and C7 lamina. A distal lateral laminectomy was then performed with great care not to injure the underlying dura. For this a 1-mm Kerrison was utilized. The laminectomy was extended towards the area under the facet joint, we were immediately able to identify the proximal C7 nerve root within the most medial part of the foramen. The foraminotomy was then completed by carefully drilling away this bilateral mass and facet structure until it was paper thin.
The remaining part of the facetectomy was then performed with the use of the #1 Kerrison rongeur. In doing so, we were able to expose the nerve root from its origin at the thecal sac to just before its exit in the foramen where it was no longer being compressed. The foramen at this point appeared to be adequately decompressed as we were able to introduce a dental tool with great (ease) and without any evidence of the nerve root itself being pinched up. Having completed this foraminotomy, the nerve root was covered with a thin Gelfoam and we turned out our attention to the foraminotomy at C5-6. Similarly, a distal laminectomy was performed and the facetectomy was performed by first drilling with a small air drill and removing the facet with a #1 Kerrison rongeur. Similarly, we were able to perform decompression of the entire nerve root, which could be visualized on exit of the thecal sac until just about its exit from the foramen itself. Upon conclusion, it was ascertained that the nerve root was adequately decompressed. We similarly introduced a dental instrument into the foramen and being able to move them freely we could conclude that the nerve root was adequately decompressed.
Both nerve roots were then covered with a small amount of Depo-Medrol solution and then with Gelfoam. Bleeding from the bone was contained with the use of bone wax and small bleeding from soft tissues was stopped using a bipolar cautery. All retractors were then removed and after leaving a Hemovac in the paravertebral musculature immediately overlying the lamina, we turned our attention to the closure. Muscles were brought back together with 0-Vicryl as was the cervical fascia. Subcutaneous tissues were brought back together with 3-Vicryl and skin edges were brought back together with skin staples.
On conclusion, the incision was cleaned with Betadine and sterile dressing was applied in usual fashion. At this point, the patient was transferred to the stretcher in the supine position where Mayfield pinhead holder was removed, general anesthesia was reversed and she was extubated. Upon extubation, she was sleepy but arousable. She was following simple commands and she was moving all her extremities without any evidence of weakness. Her right arm was weak more so biceps and triceps and she had full use of the arm in the recovery room.
The patient tolerated the procedure well and there were no intraoperative complications. At this point, the patient was transferred to the recovery room in stable condition for further monitoring.
Deon Thompson, M.D.
Electronically signed by DEON THOMPSON, MD 1/1/20XX
How do I know that I should report 63020 instead of 63045?