ksrkelly7
Networker
Hi there,
I am new to coding neuro surgery and would like some help please. These are the codes I'm thinking, but I'm not sure and would like some clarification. This is a Medicare patient.
63081 C6
22554
22845
22551 C3-4
22552 C5-6
22851 cage
22851-XS plate
20930
20936
76001-26
PREOPERATIVE DIAGNOSIS:
1. Cervical disc disease as documented on the imaging studies at C3 4 with cord compression and cord injury c 6 with cord compression cord injury C6 7 cord compression cord injury C osteophyte extending level of C7
2. Failure of conservative treatment, progressive worsening.
3. Patient presents with severe myelopathy worsening motor and sensory loss involving upper and lower extremities sensory loss lower extremities as well as uppers failure of conservative treatment_
PROCEDURE:
1. Anterior cervical diskectomy with exposure down to the dura and removal
of osteophyte at the level of C3 4 C5 6 and C6 7 , 3 levels
2. Arthrodesis fusion at the level of C3 4 C5 6 C6 7, 3 levels
3 corpectomy C6
3. Anterior segmental fixation of the cervical spine using a Synthes plate
with Apex.
4. Placement of biomechanical intervertebral body device at the level of C3 4 and the level of C5 to C7, 3 levels levels
5. Placement of both allo and auto graft
6. Intraoperative fluoroscopy for 3 hours.
INDICATIONS FOR PROCEDURE:
This patient is presenting with symptomatic cervical disease at C3 4 C56 C6 7 with large osteophyte and compression of the cord across the vertebral body of C6 severe narrowing and signs of cord injury myelopathy
The clinical course shows deterioration of myelopathy with sensory and motor loss as noted
OPERATIVE PROCEDURE:
The patient was brought to the operating room. A formal time out was done in the room.
The patient was put to sleep under general anesthesia.
His neck was shaved, prepped, and draped in sterile fashion.
Initial transverse incision was made using 10 blade.
Sharp and blunt dissection down to the spine was carried out using a combination of a knife and fine dissecting
instruments, dissection was done to expose down to the levels of C3 4 C5 6 C6 7 and was documented by intra operative fluoroscopy.
Self-retaining retractors were placed. Longus colli muscle was dissected off
the midline.The disc space was opened
Caspar pins were placed. Distraction was done.
Microscope was brought into field. Under microscopic observation, using high-
speed drill, curved curette, Kerrison and fine dissecting instruments,
decompression was carried out and exposure down to the dura. Once this was
complete and both levels were well decompressed, hemostasis was obtained.
The offending pathology of C3 4 C5 6 C6 7 was removed both centrally and out the foramen to assure that
the spinal cord and nerve roots were well decompressed, and once this was complete, hemostasis
was obtained. Measurement for an intervertebral biomechanical device was
done.
The biomechanical device was packed with both allo and autograft and placed under slight distraction
A Bengal cage was placed at the level of C6 corpectomy
Once this was complete and hemostasis was obtained, the plate was brought on
the field, measured and placement of the Synthes Apex plate was done without difficulty using skrew fixation and floroscopy.
Final X-ray confirmation was obtained as well.
Once complete hemostasis was obtained, closure was begun. Platysma was closed using up to 3-0 Vicryl, subcuticular
layer was closed using up to 3-0 Vicryl, and skin was closed with Steri-
Strips. The patient was transferred to recovery room in stable condition.
Penrose drain was left in place
Any help with this would be greatly appreciated!
Thanks,
Kelly
I am new to coding neuro surgery and would like some help please. These are the codes I'm thinking, but I'm not sure and would like some clarification. This is a Medicare patient.
63081 C6
22554
22845
22551 C3-4
22552 C5-6
22851 cage
22851-XS plate
20930
20936
76001-26
PREOPERATIVE DIAGNOSIS:
1. Cervical disc disease as documented on the imaging studies at C3 4 with cord compression and cord injury c 6 with cord compression cord injury C6 7 cord compression cord injury C osteophyte extending level of C7
2. Failure of conservative treatment, progressive worsening.
3. Patient presents with severe myelopathy worsening motor and sensory loss involving upper and lower extremities sensory loss lower extremities as well as uppers failure of conservative treatment_
PROCEDURE:
1. Anterior cervical diskectomy with exposure down to the dura and removal
of osteophyte at the level of C3 4 C5 6 and C6 7 , 3 levels
2. Arthrodesis fusion at the level of C3 4 C5 6 C6 7, 3 levels
3 corpectomy C6
3. Anterior segmental fixation of the cervical spine using a Synthes plate
with Apex.
4. Placement of biomechanical intervertebral body device at the level of C3 4 and the level of C5 to C7, 3 levels levels
5. Placement of both allo and auto graft
6. Intraoperative fluoroscopy for 3 hours.
INDICATIONS FOR PROCEDURE:
This patient is presenting with symptomatic cervical disease at C3 4 C56 C6 7 with large osteophyte and compression of the cord across the vertebral body of C6 severe narrowing and signs of cord injury myelopathy
The clinical course shows deterioration of myelopathy with sensory and motor loss as noted
OPERATIVE PROCEDURE:
The patient was brought to the operating room. A formal time out was done in the room.
The patient was put to sleep under general anesthesia.
His neck was shaved, prepped, and draped in sterile fashion.
Initial transverse incision was made using 10 blade.
Sharp and blunt dissection down to the spine was carried out using a combination of a knife and fine dissecting
instruments, dissection was done to expose down to the levels of C3 4 C5 6 C6 7 and was documented by intra operative fluoroscopy.
Self-retaining retractors were placed. Longus colli muscle was dissected off
the midline.The disc space was opened
Caspar pins were placed. Distraction was done.
Microscope was brought into field. Under microscopic observation, using high-
speed drill, curved curette, Kerrison and fine dissecting instruments,
decompression was carried out and exposure down to the dura. Once this was
complete and both levels were well decompressed, hemostasis was obtained.
The offending pathology of C3 4 C5 6 C6 7 was removed both centrally and out the foramen to assure that
the spinal cord and nerve roots were well decompressed, and once this was complete, hemostasis
was obtained. Measurement for an intervertebral biomechanical device was
done.
The biomechanical device was packed with both allo and autograft and placed under slight distraction
A Bengal cage was placed at the level of C6 corpectomy
Once this was complete and hemostasis was obtained, the plate was brought on
the field, measured and placement of the Synthes Apex plate was done without difficulty using skrew fixation and floroscopy.
Final X-ray confirmation was obtained as well.
Once complete hemostasis was obtained, closure was begun. Platysma was closed using up to 3-0 Vicryl, subcuticular
layer was closed using up to 3-0 Vicryl, and skin was closed with Steri-
Strips. The patient was transferred to recovery room in stable condition.
Penrose drain was left in place
Any help with this would be greatly appreciated!
Thanks,
Kelly