Elund
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The documentation:
How am I supposed to know that the code for the operating microscope (69990) is bundled into codes 63051 and 63001? I didn't see this specified in the guidelines for either of these codes, or in the guidelines at the beginning of the section.
OPERATIVE REPORT
SEX: FEMALE
AGE: 38
DATE: 01/1/20XX
PREOPERATIVE DIAGNOSIS: C3-7 cervical stenosis and myelopathy.
POSTOPERATIVE DIAGNOSIS: C3-7 cervical stenosis and myelopathy.
PROCEDURE:
1. C3, C4, C5, and C6 open-door laminoplasty.
2. C7 laminectomy.
3. Use of operative microscope for microsurgical dissection.
Surgeon: Cristopher Thomas, M.D.
1st Assistant: Braden Andrews, M.D.
Anesthesia: General.
Estimated Blood Loss: 100 mL.
Monitoring: SSEP monitoring was used; no change preoperative, intraoperative, and to immediate postoperative.
INDICATIONS: This is a female with cervical myelopathy following a motor vehicle accident. Her neurologic symptoms have started to deteriorate. I recommended spinal cord decompression and went over the rationale risks such as heart attack, stroke, blood clot, wound infection, chronic neck pain, residual symptoms, temporary or permanent pain, weakness in the legs, CSF leak, bowel and bladder dysfunction and permanent quadriplegia. Informed consent was obtained.
PROCEDURE: The patient was brought to the operating room anesthetized, intubated by anesthesia service. SSEP monitor was placed and a baseline recording obtained. Then placed Mayfield cranial tongs.
The patient was prone on the operating room with head in neutral positions, secured the Mayfield. All extremities were padded and secured. I prepped and draped the cervical spine sterilely. A midline incision to the base of the spinous process C3-C7 dissected subperiosteally to the junction of the lamina-lateral mass. Localizing x- ray confirmed my level. I placed deep retractors and brought in the operating microscope for microsurgical dissection. I then released the ligamentum in the midline at C2-3 and at C6-7. I then use the bur and made a full thickness trough on the right hand side and a partial thickness trough on the left hand side at the lamina-lateral mass junction. I released the ligamentum on the right hand side and then hinged open the lamina. I placed suture anchors on levels C4, C5, C6 and C7 and then passed them through the spinous process at these levels and secured open the laminoplasty with my suture anchors. The lamina opening was approximately 20 mm. I released all dural adhesions dorsally. I then removed 30% of the C7 lamina using a bur and 1 or 2 mm Kerrison. Fine decompression and dural pulsations were noted. I irrigated the wound with a liter of saline, took the operating microscope of the field. I then closed the wound layers using absorbable suture. Steri-Strips and sterile dressings were applied. Surgical field was broken down. The patient was transferred supine to the hospital bed, and removed the Mayfield cranial tongs, extubated, and brought to the recovery room moving all four extremities.
Christopher Thomas, MD
Electronically signed by CHRISTOPHER THOMAS, MD 1/1/20XX
SEX: FEMALE
AGE: 38
DATE: 01/1/20XX
PREOPERATIVE DIAGNOSIS: C3-7 cervical stenosis and myelopathy.
POSTOPERATIVE DIAGNOSIS: C3-7 cervical stenosis and myelopathy.
PROCEDURE:
1. C3, C4, C5, and C6 open-door laminoplasty.
2. C7 laminectomy.
3. Use of operative microscope for microsurgical dissection.
Surgeon: Cristopher Thomas, M.D.
1st Assistant: Braden Andrews, M.D.
Anesthesia: General.
Estimated Blood Loss: 100 mL.
Monitoring: SSEP monitoring was used; no change preoperative, intraoperative, and to immediate postoperative.
INDICATIONS: This is a female with cervical myelopathy following a motor vehicle accident. Her neurologic symptoms have started to deteriorate. I recommended spinal cord decompression and went over the rationale risks such as heart attack, stroke, blood clot, wound infection, chronic neck pain, residual symptoms, temporary or permanent pain, weakness in the legs, CSF leak, bowel and bladder dysfunction and permanent quadriplegia. Informed consent was obtained.
PROCEDURE: The patient was brought to the operating room anesthetized, intubated by anesthesia service. SSEP monitor was placed and a baseline recording obtained. Then placed Mayfield cranial tongs.
The patient was prone on the operating room with head in neutral positions, secured the Mayfield. All extremities were padded and secured. I prepped and draped the cervical spine sterilely. A midline incision to the base of the spinous process C3-C7 dissected subperiosteally to the junction of the lamina-lateral mass. Localizing x- ray confirmed my level. I placed deep retractors and brought in the operating microscope for microsurgical dissection. I then released the ligamentum in the midline at C2-3 and at C6-7. I then use the bur and made a full thickness trough on the right hand side and a partial thickness trough on the left hand side at the lamina-lateral mass junction. I released the ligamentum on the right hand side and then hinged open the lamina. I placed suture anchors on levels C4, C5, C6 and C7 and then passed them through the spinous process at these levels and secured open the laminoplasty with my suture anchors. The lamina opening was approximately 20 mm. I released all dural adhesions dorsally. I then removed 30% of the C7 lamina using a bur and 1 or 2 mm Kerrison. Fine decompression and dural pulsations were noted. I irrigated the wound with a liter of saline, took the operating microscope of the field. I then closed the wound layers using absorbable suture. Steri-Strips and sterile dressings were applied. Surgical field was broken down. The patient was transferred supine to the hospital bed, and removed the Mayfield cranial tongs, extubated, and brought to the recovery room moving all four extremities.
Christopher Thomas, MD
Electronically signed by CHRISTOPHER THOMAS, MD 1/1/20XX
How am I supposed to know that the code for the operating microscope (69990) is bundled into codes 63051 and 63001? I didn't see this specified in the guidelines for either of these codes, or in the guidelines at the beginning of the section.
