Can someone please help me with the coding of this op note. I coded it 63047 & 63048 but I am not sure if I am correct. Any help will be greatly appreciated. Thanks!
L4-5 disc herniation with stenosis and radiculopathy
I began by using a spinal needle and C-arm imaging to center my incision over the L4-5 interspace. The
skin was then anesthetized in the midline and sharply incised. Bovie cautery was used for hemostasis and
to perform a subperiosteal dissection onto the spinous processes and lamina bilaterally at L4 and L5. A
self-retaining retractor was then utilized. Again, I used C-arm imaging to verify I was centered over the
appropriate motion segment. Given her disc herniation was central, I felt it necessary to perform a wide
decompression bilaterally. I therefore used a rongeur to remove the interspinous ligaments at L4-L5. I
then used a bone scalpel to remove the lower one half of the lamina at L4 bilaterally as well as the apex of
the L5 lamina. Once the section of the bone were removed, I could identify the thecal sac in the midline.
I then worked in lateral recess and removed hypertrophic ligamentum onto the medial border of the
pedicles. I could then palpate the medial border of the pedicles bilaterally and verified the foramen were
decompressed. Any attempt to work in lateral recess showed ongoing nerve irritation secondary to the
disc herniation.
I then brought a microscope in from the left side of the patient, I diligently worked to retract the dura and
was able to identify the central disc herniation with the dura protected. I used a scalpel to perform an
annulotomy. I could then use a nerve hook to work in the disc herniation. This was quite hard and
seemed chronic. I was able to express some small fragments of acute/soft disc herniation, but this was
completed. The nerve roots were completely decompressed in the lateral recess. There was still some
disc protrusion centrally which was able to be removed secondary to risk of nerve retraction.
I copiously irrigated the epidural space. No signs of CSF leak was noted throughout. I obtained epidural
venous hemostasis with injectable thrombin product and bipolar cautery. The retractor and microscope
were removed. No further bleeding was noted and I did not utilize the drain. We injected the tissues with
BKK for postoperative pain control. The fascia was closed with interrupted 0-Vicryl suture and the skin
in layers with subcuticular Monocryl for the surface. A soft sterile dressing was placed. She tolerated the
procedure well without apparent consultation. She was returned to the supine position, awoke from
anesthesia and was extubated. She was taken to Recovery in stable condition.
L4-5 disc herniation with stenosis and radiculopathy
I began by using a spinal needle and C-arm imaging to center my incision over the L4-5 interspace. The
skin was then anesthetized in the midline and sharply incised. Bovie cautery was used for hemostasis and
to perform a subperiosteal dissection onto the spinous processes and lamina bilaterally at L4 and L5. A
self-retaining retractor was then utilized. Again, I used C-arm imaging to verify I was centered over the
appropriate motion segment. Given her disc herniation was central, I felt it necessary to perform a wide
decompression bilaterally. I therefore used a rongeur to remove the interspinous ligaments at L4-L5. I
then used a bone scalpel to remove the lower one half of the lamina at L4 bilaterally as well as the apex of
the L5 lamina. Once the section of the bone were removed, I could identify the thecal sac in the midline.
I then worked in lateral recess and removed hypertrophic ligamentum onto the medial border of the
pedicles. I could then palpate the medial border of the pedicles bilaterally and verified the foramen were
decompressed. Any attempt to work in lateral recess showed ongoing nerve irritation secondary to the
disc herniation.
I then brought a microscope in from the left side of the patient, I diligently worked to retract the dura and
was able to identify the central disc herniation with the dura protected. I used a scalpel to perform an
annulotomy. I could then use a nerve hook to work in the disc herniation. This was quite hard and
seemed chronic. I was able to express some small fragments of acute/soft disc herniation, but this was
completed. The nerve roots were completely decompressed in the lateral recess. There was still some
disc protrusion centrally which was able to be removed secondary to risk of nerve retraction.
I copiously irrigated the epidural space. No signs of CSF leak was noted throughout. I obtained epidural
venous hemostasis with injectable thrombin product and bipolar cautery. The retractor and microscope
were removed. No further bleeding was noted and I did not utilize the drain. We injected the tissues with
BKK for postoperative pain control. The fascia was closed with interrupted 0-Vicryl suture and the skin
in layers with subcuticular Monocryl for the surface. A soft sterile dressing was placed. She tolerated the
procedure well without apparent consultation. She was returned to the supine position, awoke from
anesthesia and was extubated. She was taken to Recovery in stable condition.
