I'm stuck on this op note. The surgeon did a posterolatera fusion at levels L3-4 & L4-5 and this is from his op note:
A 20 centimeter incision over the posterior aspect of his lower back. The incision was taken down to the level of the dorsolumbar fascia. The dorsolumbar fascia was incised with cautery and the exposure taken down to the level of the lamina. Scout film was done to verify that we were at the pedicle of L4 and the spinous process of L4. Further exposure was done to fully show the L2 to S1 junctions. Once we were able to do this, we were able to do a bilateral laminectomy at all levels beginning with L2-3, followed by L3-4, L4-5, and L5-S1. We followed this up by doing bilateral medial facetectomies, followed by bilateral foraminotomies at L2-3, L3-4, L4-5, and L5-S1. Using our usual landmarks at 6.5 x 40 millimeter screws were placed bilaterally at L3, L4, and L5. Thereafter we were able to verify that we were able to free the nerves as previously stated at the foraminotomies and the laminectomies.
Once this was ascertained and the screws were tested, and x-rays were done to visualize their appropriate placement, we were able to put 60 millimeter rods in the screw heads and place the set screws and get another x-ray to verify that lordosis was adequate. Thereafter, after counter-torquing the set screws, we were able to put some of the patient's autograft in the lateral gutters. Once this was done, 1 gram of Vancomycin was placed on the hardware. Subsequently we were able to put a 15 large drain deep to the fascia and a 10 small drain above the fascia. Thereafter the subcutaneous tissue was closed with #2 Vicryl followed by closure of the skin with staples. Please note that the dorsolumbar fascia was closed #1 Vicryl. Subsequently patient was taken to the Intensive Care Unit with no complications.
Would I code the fusions as a 22612 or 22633???
Thanks, Meg
A 20 centimeter incision over the posterior aspect of his lower back. The incision was taken down to the level of the dorsolumbar fascia. The dorsolumbar fascia was incised with cautery and the exposure taken down to the level of the lamina. Scout film was done to verify that we were at the pedicle of L4 and the spinous process of L4. Further exposure was done to fully show the L2 to S1 junctions. Once we were able to do this, we were able to do a bilateral laminectomy at all levels beginning with L2-3, followed by L3-4, L4-5, and L5-S1. We followed this up by doing bilateral medial facetectomies, followed by bilateral foraminotomies at L2-3, L3-4, L4-5, and L5-S1. Using our usual landmarks at 6.5 x 40 millimeter screws were placed bilaterally at L3, L4, and L5. Thereafter we were able to verify that we were able to free the nerves as previously stated at the foraminotomies and the laminectomies.
Once this was ascertained and the screws were tested, and x-rays were done to visualize their appropriate placement, we were able to put 60 millimeter rods in the screw heads and place the set screws and get another x-ray to verify that lordosis was adequate. Thereafter, after counter-torquing the set screws, we were able to put some of the patient's autograft in the lateral gutters. Once this was done, 1 gram of Vancomycin was placed on the hardware. Subsequently we were able to put a 15 large drain deep to the fascia and a 10 small drain above the fascia. Thereafter the subcutaneous tissue was closed with #2 Vicryl followed by closure of the skin with staples. Please note that the dorsolumbar fascia was closed #1 Vicryl. Subsequently patient was taken to the Intensive Care Unit with no complications.
Would I code the fusions as a 22612 or 22633???
Thanks, Meg