rbrandonisio
New
I am newer to Neurosurgery and my doctor is questioning my coding for this op note: dx is
Left L5-S1 foraminal stenosis
PROCEDURE: After proper identification, the patient was taken to the operating room and placed under general anesthesia. All appropriate lines were placed by anesthesia team. He was positioned prone on a Wilson frame with all pressure points padded. He received prophylactic antibiotics prior to skin incision.
The lumbar area was prepped and draped in sterile fashion. A spinal needle was then inserted at the left L5-S1 facet and fluoroscopy used to confirm the appropriate level of surgery. Through this needle, local anesthetic was injected at the facet as well as along the tracts towards the skin. After skin incision, electrocautery was used for subcutaneous hemostasis. A K-wire was then inserted through the lumbosacral fascia to the left L5-S1 facet. Fluoroscopy confirmed appropriate placement of the wire. Over the wire METRx dilators were placed and then an 18 mm tube positioned.
At this point, the microscope was brought into the field. Fluoroscopy showed good placement of the METRx tube. The left hemi-laminae of L-5 as well as the pars interaticularis were cleaned of any overlying soft tissue with cautery. High-speed drill was then used to perform a foraminotomy at the junction of the lateral pars interaticularis and superior facet. The ligamentum flavum was then elevated and removed in piecemeal fashion to expose the exiting L5 nerve root. At the end there was good decompression and the nerve root appeared free. FloSeal was applied for hemostasis and copious wound irrigation performed. DepoMedrol was injected into the epidural space surrounding the nerve root. Local anesthetic was injected into the skin and muscle. The incision was closed in layered fashion with Prineo on the skin. All counts were correct. Sterile dressing was applied. The patient was extubated and transported to recovery in stable condition.
I thought it should be 63047.
Any help would be appreciated
Left L5-S1 foraminal stenosis
PROCEDURE: After proper identification, the patient was taken to the operating room and placed under general anesthesia. All appropriate lines were placed by anesthesia team. He was positioned prone on a Wilson frame with all pressure points padded. He received prophylactic antibiotics prior to skin incision.
The lumbar area was prepped and draped in sterile fashion. A spinal needle was then inserted at the left L5-S1 facet and fluoroscopy used to confirm the appropriate level of surgery. Through this needle, local anesthetic was injected at the facet as well as along the tracts towards the skin. After skin incision, electrocautery was used for subcutaneous hemostasis. A K-wire was then inserted through the lumbosacral fascia to the left L5-S1 facet. Fluoroscopy confirmed appropriate placement of the wire. Over the wire METRx dilators were placed and then an 18 mm tube positioned.
At this point, the microscope was brought into the field. Fluoroscopy showed good placement of the METRx tube. The left hemi-laminae of L-5 as well as the pars interaticularis were cleaned of any overlying soft tissue with cautery. High-speed drill was then used to perform a foraminotomy at the junction of the lateral pars interaticularis and superior facet. The ligamentum flavum was then elevated and removed in piecemeal fashion to expose the exiting L5 nerve root. At the end there was good decompression and the nerve root appeared free. FloSeal was applied for hemostasis and copious wound irrigation performed. DepoMedrol was injected into the epidural space surrounding the nerve root. Local anesthetic was injected into the skin and muscle. The incision was closed in layered fashion with Prineo on the skin. All counts were correct. Sterile dressing was applied. The patient was extubated and transported to recovery in stable condition.
I thought it should be 63047.
Any help would be appreciated