maljdcpc
Networker
Need help coding the following spine surgery. I don't think there is enough documentation for laminectomy but I cound be wrong...? Dr just states 'decompress the foramen...once we had finished decompression'. (There is nothing about removal of lamina or freeing nerve roots from any compression.) Arthrodesis- Dr states ' We then decorticated along the transverse processes and along the sacral ala. (Does not state at L4 L5 level along transverse process and S1 along the sacral ala) Also for autograft bone graft Dr. only states 'some local bone we
obtained'. Is this enough documentation to code the following CPT codes Dr. listed or am I being to nitpicky? Any help would be greatly appreciated!
22612- Arthrodesis
22614- Arthrodesis each addtl segment
22842- Instrumentation
63047- Laminectomy
63048- Laminectomy each addtl
20936- Autograft bone graft
20930- Allograft bone graft
POSTOPERATIVE DIAGNOSES: Spinal stenosis, spondylolisthesis L4-L5, and
L5-S1.
PROCEDURES: Lumbar fusion, posterior lateral L4-L5, L5-S1 decompression and
foraminal L4-L5, L5-S1 and pedicle screws L4, L5 and S1 bilaterally,
posterolateral bone graft and infuse and demineralized bone matrix.
PROCEDURE: The patient was placed under general anesthesia. We placed
prone on a Wilson frame. We padded all prominent areas. We then did an
appropriate time-out and then made a midline incision, and then a paraspinal
approach. We incised through the lumbosacral fascia and bluntly dissected
down to the bone. We extended down to the transverse processes of L4, L5 and
then the sacral ala of S1. Once we had completed our exposure, we then took
an intraoperative x-ray, confirmed where we were. We then proceeded to
decompress the foramen. We just wanted to make sure especially at the
L4-L5, there was no severe stenosis or impingement because he did not have
any _____ stenosis, mostly foraminal and he had spinal instability, which
was causing probably most of the symptoms. Once we had finished a
decompression and we then proceeded to place 6 pedicle screws. We used the 3
view C-arm. We used a Jamshidi needle, which went into the pedicle and into
the vertebral body. We then placed a guidewire through the Jamshidi needle
and we did at 6 locations pedicle L4 right and left, L5 right and left and
sacral ala, right and left. We then checked the position, rotated the C-arm,
3 views, we had excellent interpedicular positioning. We then proceeded to
place 4, #40 _____ pedicle screws over each of the guidewires. Once we had
completed placement of the screws, we then placed two connecting rods. One
on each side, we fashioned and we placed in a little bit of lordosis and
then we secured them in with the connecting and locking bolts. We then
decorticated along the transverse processes and along the sacral ala. We
placed a strip of infuse and then we used some DBM and some local bone we
obtained and placed it along the lateral. We then placed the bone graft out
laterally. We then irrigated, let the fascia fall back in place. We closed both fascial
incisions with running Vicryl stitch, closed the skin with 2-0
and staples. We applied a bulky dressing and awoke the patient and
transferred to the recovery room.
obtained'. Is this enough documentation to code the following CPT codes Dr. listed or am I being to nitpicky? Any help would be greatly appreciated!
22612- Arthrodesis
22614- Arthrodesis each addtl segment
22842- Instrumentation
63047- Laminectomy
63048- Laminectomy each addtl
20936- Autograft bone graft
20930- Allograft bone graft
POSTOPERATIVE DIAGNOSES: Spinal stenosis, spondylolisthesis L4-L5, and
L5-S1.
PROCEDURES: Lumbar fusion, posterior lateral L4-L5, L5-S1 decompression and
foraminal L4-L5, L5-S1 and pedicle screws L4, L5 and S1 bilaterally,
posterolateral bone graft and infuse and demineralized bone matrix.
PROCEDURE: The patient was placed under general anesthesia. We placed
prone on a Wilson frame. We padded all prominent areas. We then did an
appropriate time-out and then made a midline incision, and then a paraspinal
approach. We incised through the lumbosacral fascia and bluntly dissected
down to the bone. We extended down to the transverse processes of L4, L5 and
then the sacral ala of S1. Once we had completed our exposure, we then took
an intraoperative x-ray, confirmed where we were. We then proceeded to
decompress the foramen. We just wanted to make sure especially at the
L4-L5, there was no severe stenosis or impingement because he did not have
any _____ stenosis, mostly foraminal and he had spinal instability, which
was causing probably most of the symptoms. Once we had finished a
decompression and we then proceeded to place 6 pedicle screws. We used the 3
view C-arm. We used a Jamshidi needle, which went into the pedicle and into
the vertebral body. We then placed a guidewire through the Jamshidi needle
and we did at 6 locations pedicle L4 right and left, L5 right and left and
sacral ala, right and left. We then checked the position, rotated the C-arm,
3 views, we had excellent interpedicular positioning. We then proceeded to
place 4, #40 _____ pedicle screws over each of the guidewires. Once we had
completed placement of the screws, we then placed two connecting rods. One
on each side, we fashioned and we placed in a little bit of lordosis and
then we secured them in with the connecting and locking bolts. We then
decorticated along the transverse processes and along the sacral ala. We
placed a strip of infuse and then we used some DBM and some local bone we
obtained and placed it along the lateral. We then placed the bone graft out
laterally. We then irrigated, let the fascia fall back in place. We closed both fascial
incisions with running Vicryl stitch, closed the skin with 2-0
and staples. We applied a bulky dressing and awoke the patient and
transferred to the recovery room.
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