stephross97
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I am attaching a chart note and I am hoping someone can help me. I haven't done spinal coding before so any help is appreciated.
PROCEDURES
1. Bilateral facetectomies at the L3-L4, L4-5, L5-S1 levels complete decompression of all neural elements.
2. Placement of bilateral pedicle screws using the Medtronic Solera implant system with 6.5 x 50 mm screws being placed at L3, a 6.5 x 50mm screws system with 6.5 x 50 mm screws being placed at L3, 6.5 x 50 mm screws being place at L5, a 6.5 x 50 mm on the patient's left at S1, and a 6.5 x 45 mm screw on the patient's right at S1. All screws were placed using image guidance navigation.
3. Annulotomies and diskectomies bilaterally with placement of two 10 x 22 mm grafts at L5-S1 in PLIF fashion, two 10 x 26 mm grafts at L4-5 in PLIF fashion, and two 10 x 26 mm grafts at L3-4 in PLIF fashion. Interbody grafts were Medtronic capstone interbody grafts filled with DBM. All grafts were places also under image guidance.
4. Decortication of lateral processes with placement of a mixture of autograft, allograft, and DBM for posterolateral fusion. A 110 mm rod was placed on the left and a 100 mm rod was placed on the right, and they were locked down with locking end caps. A Crosslink was placed in between the L3-4 interspace. Again, all implants and screws were placed under image guidance.
Thank you in advance for any and all help.
PROCEDURES
1. Bilateral facetectomies at the L3-L4, L4-5, L5-S1 levels complete decompression of all neural elements.
2. Placement of bilateral pedicle screws using the Medtronic Solera implant system with 6.5 x 50 mm screws being placed at L3, a 6.5 x 50mm screws system with 6.5 x 50 mm screws being placed at L3, 6.5 x 50 mm screws being place at L5, a 6.5 x 50 mm on the patient's left at S1, and a 6.5 x 45 mm screw on the patient's right at S1. All screws were placed using image guidance navigation.
3. Annulotomies and diskectomies bilaterally with placement of two 10 x 22 mm grafts at L5-S1 in PLIF fashion, two 10 x 26 mm grafts at L4-5 in PLIF fashion, and two 10 x 26 mm grafts at L3-4 in PLIF fashion. Interbody grafts were Medtronic capstone interbody grafts filled with DBM. All grafts were places also under image guidance.
4. Decortication of lateral processes with placement of a mixture of autograft, allograft, and DBM for posterolateral fusion. A 110 mm rod was placed on the left and a 100 mm rod was placed on the right, and they were locked down with locking end caps. A Crosslink was placed in between the L3-4 interspace. Again, all implants and screws were placed under image guidance.
Thank you in advance for any and all help.