NESmith
Expert
Please help. Spine surgery is really getting the best of me. How would you code this?
Pre-op dx: 1.Cervical degenerative disk disease. 2. Cervical stenosis 3. Cervical spondylosis 4. Cervical radiculopathy
Post-op dx: same as above
Procedure performed:
1. Anterior cervical discectomy and fusion C4-C5, C5-C6, C6-C7
2. Partial corpectomy C5
3. Partial corpectomy, C6
4. Partial corpectomy, C7
Procedure A left-sided incision was made and Smith Robinson approach was utilized to dissect down to the ventral aspect of the cervical spine. We localized the levels radiographically and elevated the longus collo from the mid body of C4 to the mid body of C7. We then placed shadow line retractors over the C4-C5 disc space and performed a discectomy in standard fashion and the discectomy was carried down to the level of the posterior longitudinal ligament. We retrieved one fragment of disc from the midline where ther was a disruption of the posterior longitudinal ligament. otherwise, there was minimal canal or foraminal disease at this level. We then placed a size 7 cortical cancellous spacer and moved the Caspar pins over the C5-C6 diisc space where ventral osteophytes were resected as well as posterior osteophyte and foraminal osteophyte affecting a subtotal corpectomy throughout the course of the discectomy. Bilateral anterior foraminotomies were performed and the posterior longitudinal ligament was taken down bilaterally, centrally was left intact. we placed a size 8 cortical cancellous spacer, moved the Caspar pins to the C6-C7 disc space and in a similar fashion during our diskectomy, resected the ventral posterior foraminal osteophyte affecting a subtotal corpectomy of C6 and C7 to obtain complete decompression. We then placed a size 8 cortial cancellous spacer and removed the Caspar pins in the shadow line rectors. An anterior cervical plate by Medtronic was placed on the ventral aspect of the cervical spine and intraoperative AP and lateral radiographs were obtained, which confirmed postiton of all implants and grafts. we ensured absolute hemostasis, a deep drain was placed. the wound was closed in layers. The patient awoke without event and was taken to the recovery room in stable condition.
CPT codes used; 63081, 63082 x2, 22551, 22552 x2, 22846, 22851x2, 20931, and 20936.
I do not feel these are all correct. Please give me your opinion and also Thanks for all your help.
Pre-op dx: 1.Cervical degenerative disk disease. 2. Cervical stenosis 3. Cervical spondylosis 4. Cervical radiculopathy
Post-op dx: same as above
Procedure performed:
1. Anterior cervical discectomy and fusion C4-C5, C5-C6, C6-C7
2. Partial corpectomy C5
3. Partial corpectomy, C6
4. Partial corpectomy, C7
Procedure A left-sided incision was made and Smith Robinson approach was utilized to dissect down to the ventral aspect of the cervical spine. We localized the levels radiographically and elevated the longus collo from the mid body of C4 to the mid body of C7. We then placed shadow line retractors over the C4-C5 disc space and performed a discectomy in standard fashion and the discectomy was carried down to the level of the posterior longitudinal ligament. We retrieved one fragment of disc from the midline where ther was a disruption of the posterior longitudinal ligament. otherwise, there was minimal canal or foraminal disease at this level. We then placed a size 7 cortical cancellous spacer and moved the Caspar pins over the C5-C6 diisc space where ventral osteophytes were resected as well as posterior osteophyte and foraminal osteophyte affecting a subtotal corpectomy throughout the course of the discectomy. Bilateral anterior foraminotomies were performed and the posterior longitudinal ligament was taken down bilaterally, centrally was left intact. we placed a size 8 cortical cancellous spacer, moved the Caspar pins to the C6-C7 disc space and in a similar fashion during our diskectomy, resected the ventral posterior foraminal osteophyte affecting a subtotal corpectomy of C6 and C7 to obtain complete decompression. We then placed a size 8 cortial cancellous spacer and removed the Caspar pins in the shadow line rectors. An anterior cervical plate by Medtronic was placed on the ventral aspect of the cervical spine and intraoperative AP and lateral radiographs were obtained, which confirmed postiton of all implants and grafts. we ensured absolute hemostasis, a deep drain was placed. the wound was closed in layers. The patient awoke without event and was taken to the recovery room in stable condition.
CPT codes used; 63081, 63082 x2, 22551, 22552 x2, 22846, 22851x2, 20931, and 20936.
I do not feel these are all correct. Please give me your opinion and also Thanks for all your help.
