# Alif l5-s1



## nlbarnes (Feb 22, 2017)

Doctor has 22558, 22853, 22612, 22840

Shouldn't 22840 be 22845 and any other corrections?

POSTOPERATIVE DIAGNOSES: 
1.  Isthmic spondylolisthesis, L5-S1. 
2.  Bilateral pars defects chronic L5. 
3.  Foraminal stenosis, bilateral L5-S1. 

PROCEDURES: 
1.  Anterior lumbar interbody fusion with placement of interbody 
    fusion device and buttress plate fixation, L5-S1. 
2.  Posterior spinal fusion with instrumentation, L5-S1. 

IMPLANTS: 
SeaSpine a-POD PEEK/ titanium interbody fusion device L5-S1 and 
SeaSpine spin plate titanium buttress plate fixation, L5-S1. 
Posterior instrumentation was Medtronic Legacy titanium pedicle screw 
system, L5-S1. 

DESCRIPTION OF PROCEDURE: 
The patient was taken to the operating room, placed in a supine 
position on the gurney, where general anesthesia obtained.  The 
patient was then carefully transitioned to the operating table to 
allow for anterior approach to the lumbar spine.  All pressure points 
were appropriately padded.  Abdomen was then prepped and draped in 
normal sterile fashion.  Surgical time-out completed.  Appropriate 
operative level was confirmed with intraoperative fluoroscopy.  Once 
appropriate levels identified, Dr. D then performed an 
anterior exposure of the lumbar spine at L5-S1 and this will be 
dictated under separate operative note.  Once Dr. D provided 
exposure, annulotomy was created at L5-S1 after appropriate 
confirmation of visualization on x-ray of the appropriate operative 
level.  Annulotomy was created anteriorly.  Serial curettage of the 
disk space was then performed.  Appropriate size implant was then 
selected to match patient anatomy, and with the placement of the 
anterior interbody device, there was excellent interference fit of the 
implant as well as reduction of the spondylolisthesis approximately 
50% which was simply the anterior based interbody procedure alone. 
The appropriate size implant was selected, appropriate position within 
the intervertebral space, and then buttress plate fixation was engaged 
spanning the intervertebral space creating fixation at L5 and S1 
respectively at the point of implant fixation.  With stable anterior 
end plate fixation completed, the anterior component of the procedure 
was completed.  Final fluoroscopic imaging showed excellent position 
of the implant on both AP and lateral fluoroscopic imaging and all 
sponges and instrumentation removed from the abdomen.  The wound was 
then closed in layers and sterile dressing was placed.  The patient 
was then carefully rolled to the prone position on Jackson table with 
all pressure points appropriately padded.  Back was then prepped and 
draped in normal sterile fashion.  Surgical time-out was completed. 
Two paramedian incisions were made over the starting points of the L5 
and S1 pedicles respectively.  Skin and subcutaneous tissues dissected 
sharply.  The investing fascia of the posterior spinal muscle was then 
divided longitudinally using Bovie electrocautery.  Blunt dissection 
of the posterior spinal musculature was then performed.  Using Bovie 
electrocautery, the sacral ala of S1 was exposed bilaterally.  The 
transverse process of L5 were exposed bilaterally.  These were 
decorticated using a high-speed burr and then the decorticated bone 
was mixed with some additional beta-tricalcium phosphate and then this 
graft material was packed densely over the exposed decorticated bony 
elements from L5-S1 respectively.  Cannulated needles were then 
utilized to cannulate the pedicles of L5 and S1 respectively with care 
taken to maintain the needle tips lateral to the medial pedicle wall 
during the traverse of the pedicles bilaterally.  Guidewires were then 
placed through the pedicle into the vertebral bodies bilaterally with 
excellent wire position confirmed with AP and lateral fluoroscopic 
imaging.  The pedicle channels were then carefully tapped. 
Appropriate-sized screws were then selected to match patient anatomy, 
seated over the guidewires through the pedicles and the vertebral 
bodies bilaterally with excellent screw purchase achieved at all 4 
screw points.  The connecting rods for the system were then placed 
within the multiaxial heads of the system and with final tightening, 
there was some additional reduction of the spondylolisthesis was well 
as restoration of lordosis using the lordosis created on the Jackson 
table to maximize lordotic position at L5-S1.  Final tightening of the


----------



## mhstrauss (Feb 22, 2017)

nlbarnes said:


> Doctor has 22558, 22853, 22612, 22840
> 
> Shouldn't 22840 be 22845 and any other corrections?
> 
> ...





My thoughts are:

22558 for ALIF
22859 for cage--I don't see graft material documented with anterior approach to complete the interbody arthrodesis
22612 for posterior fusion
22840 for posterior nonsegmental instrumentation
20930 for allograft
20936 for autograft

For the buttress plate mentioned, I would get clarification from the surgeon on whether or not that is truly a separate plate. The buttress plates my docs use are typically part of the cage, just to secure the cage to the vertebra above and below, which does not justify billing 22845. If he DID use a separate plate for independent stabilization, then add 22845 also. And of course, add appropriate co-sx and multiple procedure modifiers.

HTH!


----------



## nlbarnes (Feb 22, 2017)

*Alif*

Hi Meagan - here is the ALIF portion from the vascular surgeon.  The first report was the ortho's I'm sure you realized.  Thanks!

DESCRIPTION OF PROCEDURE: 
This was taken down through the subcutaneous tissue to expose the anterior rectus sheath.  The 
anterior rectus sheath was divided to expose the rectus muscle.  The 
rectus muscle was retracted medially to expose the posterior sheath. 
The posterior sheath was divided into the retroperitoneal space.  The 
retroperitoneal space was developed to expose the psoas muscle and the 
iliac vessels.  At that point, the abdominal contents and the ureter 
were retracted medially.  We dissected medial to the iliac vessels and 
they were retracted laterally.  The broad expanse of L5-S1 was 
exposed.  The sacral vessels were ligated and divided.  We confirmed 
disk space with fluoroscopic landmarks. 

Dr. B then entered for diskectomy and placement of 
intervertebral biomechanical device.  This required the use of 
multiple trial prostheses requiring removal and replacement of the
retractors on multiple occasions.  With the final prosthesis in place, 
anterior fixation was provided using spin plate fixation, this was to 
prevent anterior extrusion.  We then assured hemostasis.  We removed 
all sponges, retractors, and performed final imaging.  With final 
imaging found to be satisfactory, we allowed the abdominal contents to 
fall back in place and closed.  We closed the posterior sheath using 0 
Vicryl in running fashion.  We closed the anterior sheath using 0


----------



## mhstrauss (Feb 22, 2017)

nlbarnes said:


> Hi Meagan - here is the ALIF portion from the vascular surgeon.  The first report was the ortho's I'm sure you realized.  Thanks!
> 
> DESCRIPTION OF PROCEDURE:
> This was taken down through the subcutaneous tissue to expose the anterior rectus sheath.  The
> ...





Is this to clarify whether or not separate plate was used? Based on the statement "this was to prevent anterior extrusion", I would not bill a separate plate.


----------

