KristieStokesCPC
Expert
Hi all!! Would this code to 63030 or 63047? The physician strongly feels 63047 because he did not do a discectomy.
The patient was brought to the operating room and underwent an uneventful general endotracheal intubation. She was turned prone on the operating room table on the Wilson frame with her arms stretched over her head. The Wilson frame was cranked to obtain maximum kyphosis. Using a lumbar puncture needle, we identified the L4-L5 interspace. The patient was prepped and draped in a sterile fashion and a small incision was made around this mark. Using #10 blade, the incision was made and Bovie cautery was used to dissect down through the subcutaneous tissue to dorsolumbar fascia. Using a Cobb retractor, we retracted the soft tissue off of the spinous process and the lamina, after the use of the Bovie cautery, we took the muscle off of the bone and the lamina and the spinous process. We put a _____ (02:54) needle at L4 to make sure we were at the correct level and thinks that her on the L4-L5 disc space seen that we were. We then used a 5 mm diamond drill as well as 2-3 mm punch in order to form a laminotomy at L4-L5. We then used a small curette to take the ligament off of the top of L5 and used 2-4 mm punches to open up the space between the L4 and L5 lamina. After this was done, we _____ (03:26) the thecal sac at the level as well as took off the L5 nerve root.
We completed a laminotomy and foraminotomy and _____ (03:35) disc, there was no obvious disc bulge, so we passed the Woodson elevator below the pedicle at L5 to make sure that we were free. We then took an x-ray to make sure we were again at the correct level and that we were. We used FloSeal and bipolar to obtain hemostasis. We irrigated the wound copiously with antibiotic impregnated irrigation and closed the wound with a series of #0 Vicryl sutures in the dorsal lumbar fascia, 2-0 Vicryl sutures in the Scarpa's layer and deep dermal layer of skin, and 4-0 undyed Vicryl for suture for the surface of the skin. We dressed the wound with Mastisol, Steri-Strips, 4x4s, and Tegaderm. The patient was returned supine and moving her lower extremities as well.
Thanks!
The patient was brought to the operating room and underwent an uneventful general endotracheal intubation. She was turned prone on the operating room table on the Wilson frame with her arms stretched over her head. The Wilson frame was cranked to obtain maximum kyphosis. Using a lumbar puncture needle, we identified the L4-L5 interspace. The patient was prepped and draped in a sterile fashion and a small incision was made around this mark. Using #10 blade, the incision was made and Bovie cautery was used to dissect down through the subcutaneous tissue to dorsolumbar fascia. Using a Cobb retractor, we retracted the soft tissue off of the spinous process and the lamina, after the use of the Bovie cautery, we took the muscle off of the bone and the lamina and the spinous process. We put a _____ (02:54) needle at L4 to make sure we were at the correct level and thinks that her on the L4-L5 disc space seen that we were. We then used a 5 mm diamond drill as well as 2-3 mm punch in order to form a laminotomy at L4-L5. We then used a small curette to take the ligament off of the top of L5 and used 2-4 mm punches to open up the space between the L4 and L5 lamina. After this was done, we _____ (03:26) the thecal sac at the level as well as took off the L5 nerve root.
We completed a laminotomy and foraminotomy and _____ (03:35) disc, there was no obvious disc bulge, so we passed the Woodson elevator below the pedicle at L5 to make sure that we were free. We then took an x-ray to make sure we were again at the correct level and that we were. We used FloSeal and bipolar to obtain hemostasis. We irrigated the wound copiously with antibiotic impregnated irrigation and closed the wound with a series of #0 Vicryl sutures in the dorsal lumbar fascia, 2-0 Vicryl sutures in the Scarpa's layer and deep dermal layer of skin, and 4-0 undyed Vicryl for suture for the surface of the skin. We dressed the wound with Mastisol, Steri-Strips, 4x4s, and Tegaderm. The patient was returned supine and moving her lower extremities as well.
Thanks!