kimmcelderry@gmail.com
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Hi there, the MD and I are trying our best to code this correctly, I say 63266-22. (He wanted 63016 with 18 units of 63048) Any thoughts or input is appreciated.
Posterior decompression, C7/T1, T1/2/3/4/5/6/7/8/9/10/11/12, T12/L1/2/3/4/5/S1/S2, microscope assisted
Post-Op Diagnosis Codes:* Epidural abscess [G06.2]
The patient was taken to the operating room and after induction of general anesthesia by the anesthesiologist, patient was positioned on the Jackson table in the prone position was flexed. Intraoperative IOM including SSEP, MEP and EMG were set for neuromonitoring. The whole back from cervical spine to sacrum was prepped and draped in usual sterile fashion. The head was stabilized with a Gardner wells tongs and 10 lbs of weight.
Midline skin incision was carried out after obtaining the radiograph confirming the level. A 20-inch incision was carried from C7 to S1 level.
Dissection was carried down into the interlaminar space of Rt C7/T1, T12-L5 from Lt side, midline bilateral from T1-T12, L3-L5 and L5-S1 from Rt side.
Then we did total laminectomy T2, 4, 6, 8, 10 and removed distal T1, 3, 5, 7, 9 with cranial T11 lamina to decompress all thoracic levels from T2 to T11 level using variable sized Kerrison rongeurs, pituitary rongeurs, 20 mm bone scalpel under microscopic field. We found significant pus collection at all levels with epidural phlegmon.
Then, we removed Lt side C7/T1 interspace and ligamentum flavum, and decompressed C7/T1 level.
From T12 to L5, we removed interlaminar space from T12 to L5 from Lt side. After Lt side hemilaminectomy we decompressed the central ligamentum flavum and contralateral lamina cross the midline with preserving contralateral muscle and ligaments to drain the abscess.
Finally we approached and decompressed L3-S2 from Rt side with the similar fashion.
Then, the epidural space, paravertebral muscles, L4/5 Lt facet joint were irrigated, using 12 L of sterile saline. The decompressed levels were confirmed again with a radigraph. A careful hemostasis was achieved. Then, the wound was closed over deep fascial drain. The skin was closed using running stitch. Sterile dressing was applied. The patient was turned supine. The patient was awoken and then extubated, and transferred to the recovery room in good condition.
Thanks for any help!
Posterior decompression, C7/T1, T1/2/3/4/5/6/7/8/9/10/11/12, T12/L1/2/3/4/5/S1/S2, microscope assisted
Post-Op Diagnosis Codes:* Epidural abscess [G06.2]
The patient was taken to the operating room and after induction of general anesthesia by the anesthesiologist, patient was positioned on the Jackson table in the prone position was flexed. Intraoperative IOM including SSEP, MEP and EMG were set for neuromonitoring. The whole back from cervical spine to sacrum was prepped and draped in usual sterile fashion. The head was stabilized with a Gardner wells tongs and 10 lbs of weight.
Midline skin incision was carried out after obtaining the radiograph confirming the level. A 20-inch incision was carried from C7 to S1 level.
Dissection was carried down into the interlaminar space of Rt C7/T1, T12-L5 from Lt side, midline bilateral from T1-T12, L3-L5 and L5-S1 from Rt side.
Then we did total laminectomy T2, 4, 6, 8, 10 and removed distal T1, 3, 5, 7, 9 with cranial T11 lamina to decompress all thoracic levels from T2 to T11 level using variable sized Kerrison rongeurs, pituitary rongeurs, 20 mm bone scalpel under microscopic field. We found significant pus collection at all levels with epidural phlegmon.
Then, we removed Lt side C7/T1 interspace and ligamentum flavum, and decompressed C7/T1 level.
From T12 to L5, we removed interlaminar space from T12 to L5 from Lt side. After Lt side hemilaminectomy we decompressed the central ligamentum flavum and contralateral lamina cross the midline with preserving contralateral muscle and ligaments to drain the abscess.
Finally we approached and decompressed L3-S2 from Rt side with the similar fashion.
Then, the epidural space, paravertebral muscles, L4/5 Lt facet joint were irrigated, using 12 L of sterile saline. The decompressed levels were confirmed again with a radigraph. A careful hemostasis was achieved. Then, the wound was closed over deep fascial drain. The skin was closed using running stitch. Sterile dressing was applied. The patient was turned supine. The patient was awoken and then extubated, and transferred to the recovery room in good condition.
Thanks for any help!