# Stuck



## becka95 (May 30, 2011)

Ths op report is haunting me and I can't seem to figure out what the problem is. I think that I am missing a Dx Code but I am not sure. It could be missing a CPT too

My Dx codes: 996.78
CPT: 22830 51, 22840, 20930, 22630

OPERATIVE REPORT
Preoperative Diagnosis: Painful hardware versus non-union, L3-4. 
Postoperative Diagnosis: Non-union and painful hardware, L3-4. 
Operation: Hardware removal, L3-4, exploration of fusion L3-4, re-fusion in situ with bone marrow aspirate and allograft. Bone marrow from right iliac crest, approximately 15cc . 
Blood Loss: Less than 50. 
Anesthesia: General. 
HISTORY: This is a very pleasant patient with multi-level fusion, appears fused L4-5 and L5-S1, there appears to be non-union at L3-4 with some hardware lucency. Patient presents now for wound exploration, removal, possible re-fusion. Risks and benefits were discussed with her, inclusive, but not exclusive of continued pain, injury to dura, reaction to anesthesia, infection, paralysis, MI and even death. Patient understands all this and her questions were answered to the best of my ability and to her satisfaction. PROCEDURE: The patient was brought to the Operating Room, prepped and draped in the normal sterile fashion. Midline incision was made from L3 to the sacrum, carried down sharply with knife and electrocautery to the posterior spinous processes. We then dissected laterally, identifying the hardware easily and it was removed. The L4 screw was found to be tight, but L3 screw appeared to be loose and there appeared to be a fragmented fusion, but there did appear to be non-union as there was motion with flexion and extension on the screws. We then decorticated the other side and explored L4-5 and L5-S1 and found them to be solidly fused and they were left alone. We attempted to place pedicle screws with C-arm. The pedicle was so small on the right side at L3 we considered possibly re-inserting both sides, but once it was found it was not possible to place a pedicle at L3 on the right it was elected to do an in situ fusion after decorticating with bone marrow aspirate and allograft, with the slim fitting Johnson & Johnson system. We then decorticated the posterolateral recess after irrigating. Hemostasis was obtained. The fascia was then closed over a drain with interrupted 0 Vicryl, 00 Vicryl for the subcu and staples for the skin, followed by sterile dressing. The patient tolerated the procedure well and was sent to recovery stable. 

Thank you!


----------



## tcraft4 (May 31, 2011)

You might want to ask your doc about the instrumentation....reads as if only one pedicle screw was placed at L3.  Look at these codes and see what you think....22612, 22852, 38220, and 20930.   Diagnosis code 996.49 for the failed fusion along with your painful hardware code 996.78.  The exploration of fusion 22830 could be billed with modifier -59 since it was at different levels (L4-5 and L5-S1)---this would be require an operative report along with cover letter.


----------

