How would you code this 63047 or 63047 & 63048 and Why?
PROCEDURE:
After the risks, benefits and alternatives were explained to the patient and family, written informed consent was obtained, the patient brought in the operating room on a gurney and general endotracheal anesthesia was then induced. After the ET tube and lines were secured, the patient was turned prone onto a Wilson frame. All pressure points were adequately padded at this time. The surgical site area was then prepped and draped in a sterile fashion. After draping was done, a small paraspinal incision was given on the left side, centered over the L4-5 interspace, and dissection was carried down. Serial dilators were then passed and we docked a working channel sheath over the lateral lamina of L4-5 on the left side. At this point, we brought in the operating microscope, drilled the bottom lamina of L4, top lamina of L5, and the medial facet of L4-5 on the left side. Then used the Kerrison 3 and 4 mm punch to complete central and lateral recess decompression on both sides. At this point, we irrigated the wound with copious amounts of antibiotic saline. There was a dural tear which was seen on the left side over the L5 nerve root sleeve. We placed the DuraGen and DuraSeal over this and closure was then done in layers using 0 Vicryl for the fascia and subcutaneous tissue, and 3-0 nylon running locked for the skin
PROCEDURE:
After the risks, benefits and alternatives were explained to the patient and family, written informed consent was obtained, the patient brought in the operating room on a gurney and general endotracheal anesthesia was then induced. After the ET tube and lines were secured, the patient was turned prone onto a Wilson frame. All pressure points were adequately padded at this time. The surgical site area was then prepped and draped in a sterile fashion. After draping was done, a small paraspinal incision was given on the left side, centered over the L4-5 interspace, and dissection was carried down. Serial dilators were then passed and we docked a working channel sheath over the lateral lamina of L4-5 on the left side. At this point, we brought in the operating microscope, drilled the bottom lamina of L4, top lamina of L5, and the medial facet of L4-5 on the left side. Then used the Kerrison 3 and 4 mm punch to complete central and lateral recess decompression on both sides. At this point, we irrigated the wound with copious amounts of antibiotic saline. There was a dural tear which was seen on the left side over the L5 nerve root sleeve. We placed the DuraGen and DuraSeal over this and closure was then done in layers using 0 Vicryl for the fascia and subcutaneous tissue, and 3-0 nylon running locked for the skin
