Op report reads:
Procedure Performed:
L3 - L4, L4-L5, L5-S1 Laminectomy, partial facetectomy, foraminotomy, discectomy, posterolateral fusion w/Infuse, Vitoss, allograft, and instrumentation.
Technique:
"...Started our laminectomy at L5-S1 level and worked up. Carried out bilateral laminotomies @ L4-L5, L5-S1 & L3-L4 levels. First started out centrally then laterally and carried out facetectomies of about 25% on both sides @ both levels. Noted marked severe facet arthropathy on rt side of L4-L5 and L5-S1 levels. This required greater resection. Foraminotomy was carried out. Inspection of disc space identified significant disc herniations at L4-L5 and L3-L4 level. No herniation at
L5-S1 level. The level was markedly degenerated and there was foraminal stenosis, so foraminotomy was carried out. Foraminotomies and partial facetectomies were carried out at the L3-L4 and L4-L5 levels. Carried out diskectomies and bilaterally at L3-L4 and L4-L5 levels. No dural injury. There was some scarring around the nerve, particularly at the rt side of L4-L5 level. Careful lysis of adhesions was carried out and the nerve root was freed up. After multiple inspections, satisfied, retrieved all loose fragments. Wound was copiously irrigated. Then turned to screw placement."
Please help with the coding on this: I am wondering about how to code the Lysis of adhesions as well. Thank you SO much!!
Procedure Performed:
L3 - L4, L4-L5, L5-S1 Laminectomy, partial facetectomy, foraminotomy, discectomy, posterolateral fusion w/Infuse, Vitoss, allograft, and instrumentation.
Technique:
"...Started our laminectomy at L5-S1 level and worked up. Carried out bilateral laminotomies @ L4-L5, L5-S1 & L3-L4 levels. First started out centrally then laterally and carried out facetectomies of about 25% on both sides @ both levels. Noted marked severe facet arthropathy on rt side of L4-L5 and L5-S1 levels. This required greater resection. Foraminotomy was carried out. Inspection of disc space identified significant disc herniations at L4-L5 and L3-L4 level. No herniation at
L5-S1 level. The level was markedly degenerated and there was foraminal stenosis, so foraminotomy was carried out. Foraminotomies and partial facetectomies were carried out at the L3-L4 and L4-L5 levels. Carried out diskectomies and bilaterally at L3-L4 and L4-L5 levels. No dural injury. There was some scarring around the nerve, particularly at the rt side of L4-L5 level. Careful lysis of adhesions was carried out and the nerve root was freed up. After multiple inspections, satisfied, retrieved all loose fragments. Wound was copiously irrigated. Then turned to screw placement."
Please help with the coding on this: I am wondering about how to code the Lysis of adhesions as well. Thank you SO much!!