HELP...should this be coded as 63030 or 0275T?
Post operative Diagnosis:
L5-S1 spinal stenosis
Procedure performed:
L5-S1 left hemilaminectomy, partial medial facetectomy, foraminotomy, nerve root decompression.
Fluroscopic guidance was used to localize the skin landmarks. A midline incision was made over about an inch and a half. Then left sided subperiosteal elevation was done. A tube retractor was placed. Using fluoroscopic guidance, we did a partial laminectomy at the inferior lamina of L5, the medial border of the L5-S1 joint, and the sacral lamina untill we could skeletonize S1 pedicle and see the L5 and S1 roots completely and palpate them out the neural foramen. This was done with a series of high speed burrs, kerrisons, and angled curettes. Hemostasis was achieved with bipolar electrocautery, Floseal hemoststic agent, Gelfoam and thrombin. The wound was irrigated and suctioned dry.Valsalva was done. There was no signs of CSF leak. A piece of Gelfoam with steriod was placed on the nerve root at L5-S1 on the left. The wound was then closed in layers with 0 Vicryl sutures, 2-0 Vicryl sutures and staples.
Post operative Diagnosis:
L5-S1 spinal stenosis
Procedure performed:
L5-S1 left hemilaminectomy, partial medial facetectomy, foraminotomy, nerve root decompression.
Fluroscopic guidance was used to localize the skin landmarks. A midline incision was made over about an inch and a half. Then left sided subperiosteal elevation was done. A tube retractor was placed. Using fluoroscopic guidance, we did a partial laminectomy at the inferior lamina of L5, the medial border of the L5-S1 joint, and the sacral lamina untill we could skeletonize S1 pedicle and see the L5 and S1 roots completely and palpate them out the neural foramen. This was done with a series of high speed burrs, kerrisons, and angled curettes. Hemostasis was achieved with bipolar electrocautery, Floseal hemoststic agent, Gelfoam and thrombin. The wound was irrigated and suctioned dry.Valsalva was done. There was no signs of CSF leak. A piece of Gelfoam with steriod was placed on the nerve root at L5-S1 on the left. The wound was then closed in layers with 0 Vicryl sutures, 2-0 Vicryl sutures and staples.