spine coding.... please help
a midline incision was made centered over the L4-L5 interspace. the incision was carried down to skin and subcutaneous tissue. hemostasis was obtained via bovie electrocautery. Dissection was carried down to the level of fascia, and the fascia was incised on the left hand side along with the incision. dissection was carried over the spinous process of L4-L5 ligamentum flavum was dissented free from its bony attachments and removed in its entirety. portion of the inferios aspect of the L4 lamina was removed and a portion of the superior lamina of L5 was removed. a portion of the superior articular process of L5 was removed to gain access to the neural foramen. the nerve root was retracted medially. A stellate incision was made n the annulus and a large disc fragment emanated form underneath the annulus. This was removed with pituitary rongeour. additional smaller fragments were removed from within the disc space once the decompression had been performed and the discectomy completed the nerve root was felt to be completely free. a 60mm amniofix dural barrier was then placed over the exposed nerve roots and dura a 0.5 vancomycin powder was spread throughout the wound during closure. the fascia was closed and the skin closed with staples
Angelica Stephens RHIT, CPMA, COSC, CCS-P, CPC, COC.