Wiki Attempted anterior instrumentation

[SJFROEMMING]

Would anyone out there know what would be the best way to code for
attempted anterior instrumentation?

The questions is would I code for the insertion or the removal?

"I placed 1 screw in C7 and then began placing the screws into C4. The screw on the right after being placed pulled out with a light tension with
osteoporosis. I placed another one on the left side and this one
also pulled out. The two of them together in construct also were
unable to hold position. Inspection of C7 the same process
occurred with poor bone quality, unable to hold the screw into
position. High risk for pull out of the anterior cervical
instrumentation was deemed at this time. I removed the plating
system."

Any help would be appreciated. Thanks, Sue

 

[penguins11]

you would bill for the appropriate instrumentation code with a 53 modifier, look at code 22846 if that applies bill that code with a 53 modifier.