From what I can tell this is a study and it has to be unspecified, but is it Neuro (64999) or Spinal (22899). Then again there was a removal of lamina and facet material...Or is there something else that hasn't clicked in my head?
Here's the note:
North Carolina Specialty Hospital
Preoperative Diagnosis: Grade 1 spondylolisthesis, L4-5, with recurrent stenosis.
Postoperative Diagnosis: Grade 1 spondylolisthesis, L4-5, with recurrent stenosis.
Procedures: Lumbar decompression, L4-5, with re-exploration of interspace and foraminal decompression, left with iO-Flex, bilateral posterolateral fusion L4-5, bilateral pedicle instrumentation L4 and L5 bilaterally and morselized allograft. Intraoperative fluoroscopy x2 hours.
Estimated Blood Loss: 500 cc, replaced with 250 cc Cell Saver.
Drains: One medium Hemovac drain.
Complications: No complications.
Brief Clinical Note: This is a 77-year-old female who had undergone a lumbar decompression to L4-5 for primarily left hip and leg pain. She had some initial relief but then had recurrence of pain. She did get temporary response to epidural injection at L4-5 done selectively on the left. Her MRI scan shows recurrent stenosis foraminally, as well as increase in her grade 1 slip.
Operative Detail: General endotracheal anesthesia. Prone position with a Coonrad pillow, appropriately padding and positioning of the extremities. Intraoperative monitoring was set up. ChloraPrep and sterile draping in a standard fashion. Perioperative antibiotics. The previous incision was extended slightly proximally and distally and carried down to the lumbodorsal fascia exposing the spine by subperiosteal dissection preserving facet capsules until we brought fluoroscopy in for confirmation of the levels. We exposed the transverse processes of L4 and L5 and took down the capsule around the quite degenerative facets of L4 and L5 bilaterally. We then worked in the canal, along the margins, identified the bony margins and then carefully dissecting along them which allowed us to completely open up the lateral recesses on both sides. The foramen on the left was indeed tight. We used the Baxano iO-Flex device and after initially placing the guide and then the guide wire, checking its position intraoperatively with fluoroscopy, we placed the neuromonitor and assured a good threshold discrepancy. We then placed the actual blade, 5.5 mm, and under fluoroscopic guidance looked at the foraminal decompression and stopped when it appeared to be quite adequate. Her bone was fairly soft. These were withdrawn. Some compression was applied after irrigating the foramen. Facet artery was cauterized. We then placed pedicle screws again using fluoroscopy at the L4-5 bilaterally checking integrity both by direct probing, the neuromonitoring and fluoro. We then placed periallograft along the margins on each side, placed the rods which were precontoured and capped nuts and torqued them appropriately. We placed Gelfoam over the decompression regions. The wound was then closed over medium Hemovac drain with layers of
Vicryl for the lumbodorsal fascia, latissimus fascia, layers of Vicryl to the subcu and staples for the skin. Sterile dressings were applied. She was turned supine, awakened, extubated, and taken to recovery area in satisfactory condition.
- ICD-10 Training
- Exam Preparation
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join