# Posterior Cervical fusion & foraminotomies



## dhunter (Mar 18, 2010)

Need help with coding this op report please.


Procedures:

*posterior spinal fusion C2-T1

*Left foraminotomies C2-3, C3-4, C4-5, C6-7



On the left side, a motorized bur was used to perform foraminotomies at C2-3, C3-4, C4-5, C6-7 in the following fashion. A motorized bur was used to remove bone from the interlaminar facet joint region at each adjacent facet. Removal of the inferior articular process of the superior facet allowed visualization of the superior articular process of the inferior vertebra. This was thinned down to a fine cortical shell and removed with an angled cruet. Subsequently, a 1 mm Kerrison was used to widen the keyhole foraminotomy. Adequacy of decompression was assessed by palpation of the pedicle and tracing the nerve root out through the foramen.

Then attention was turned to decortication. The facet joints were decorticated bilaterally. Copious amounts of autogenous iliac crest bone graft was placed in facet joint region from C2-3 through C7-T1 bilaterally. Bone graft was placed over the decorticated lamina on the right side where foraminotomies had not been performed.

 Thanks,
Dawn


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## BCrandall (Mar 18, 2010)

63045/48's for the foraminotomy, but I'm not sure there was a fusion. Was there any spinal insturmentation or plating?


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## dhunter (Mar 18, 2010)

Instrumentation C2-T1, right iliac crest bone graft


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## BCrandall (Mar 18, 2010)

Take a look at 226xx and 2284x section of the CPT for the fusion and instrumentation. Try 2093x for the bone graft.


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## RebeccaWoodward* (Mar 18, 2010)

What about 38220 for the iliac aspiration?


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## dhunter (Mar 18, 2010)

Thanks for all the help.


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## BCrandall (Mar 18, 2010)

I didn't see any aspiration in the note Dawn posted so I figured it was a regular iliac bone graft. The note is kinda vague...


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