Can someone help me code this I am new to this kind of coding and just want to get an understanding of how to code for these procedures
PREOPERATIVE DIAGNOSIS: T11-T12 compression fracture.
POSTOPERATIVE DIAGNOSIS: T11-T12 compression fracture.
PROCEDURE PERFORMED: Left lateral thoracotomy with anterior exposure of T11 and T12, with T11-12 corpectomy with cage placement and a left eleventh partial rib resection.
DISPOSITION: The patient remained intubated in stable condition for posterior portion of the procedure. The left 28-French chest tube was to low continuous suction.
HISTORY: A 73-year-old female who has been seen by Dr. for ongoing worsening back pain due to a T11-12 compression, likely due to infection. The patient is now brought to the operating room for T12-T11 corpectomy to alleviate the compression on the spinal cord. The patient was worked up by Dr.preoperatively. The patient was also seen by me preoperatively to describe the approach through the left chest wall. Risks and benefits, alternatives were discussed to her. She agreed to proceed.
REPORT OF OPERATION: After consent was obtained, the patient was brought back to the operating room. An epidural catheter was placed. The patient was then endotracheally intubated with a double-lumen ET tube and then placed in a left lateral decubitus position, secured with a beanbag. There was an axillary roll placed and the extremities were padded and secured appropriately. The C-arm was brought in and the left chest was marked. The area of the compression was noted. The
incision was planned over top of the eleventh rib, starting anterolaterally and extending around posteriorly. After this, the left chest was prepped and draped in normal sterile fashion. Prior to incision, a timeout was performed. Dr. was present as well. All team members agreed with the procedure. After placing Ioban, the thorax was incised on the left side over top of the eleventh rib with a #10 blade, deepened down through the skin and subcutaneous tissue using cautery. Overlying musculature was divided over top of the 11th rib using cautery. I then dissected into the intercostals slightly with cautery. The lung was deflated. Using a curved 6 hemostat, the intercostals were taken down, preserving the parietal pleura. A space was dissected between the pleura and the diaphragm on the left side, dissecting down
posteriorly. The lateral aspect of the vertebral bodies could be identified. In order to assist with more visualization, it was attempted to dissect the pleura off of the spine; however, there was intense inflammation in this area and the pleura was stuck. Therefore, entry was gained into the pleura with the
lung decompressed. A Finochietto rib retractor was placed to open up the space. The dissection was completed through the intercostals. Next, a periosteal elevator was used to dissect free the posterior aspect of the 11th rib. Approximately a 1-1/2 inch segment of rib was taken with rib cutters preserving the neurovascular bundle. The Finochietto rib retractor was placed again and better exposure was taken. A moistened laparotomy sponge was used to retract the lung
cephalad. We were then able to palpate the area of concern, which was inflamed. The mid portion of the T11-T12 area was incised. There was intense inflammation in this area, which was dissected, identifying the anterior aspect of the vertebral body. I then dissected through the middle of the vertebral body. There was intense cicatrix of scar tissue. Anatomy was difficult to discern. The T12 spinal artery was identified and ligated with 3-0 Prolene stick ties divided. I then dissected up to T12 and down to L1. The L1 spinal artery was preserved and dissected so that its course could be delineated. Dr. was present and it was determined that he needed more exposure cephalad. Therefore, I dissected past T11, all the way up to the inferior aspect of T10. The T11 spinal artery was also dissected and ligated using clip
applier and 3-0 Prolene stick ties. Once the anterior aspect of all the vertebral bodies were cleared off, I did use a periosteal elevator to further clear off connective tissue along the lateral aspect of the vertebral bodies. Hemostasis was ensured. At this point, Dr. was present for his portion of the procedure. Once Dr. portion was
completed and the cage with extension was inserted and confirmed to be in correct position, I was then present to close the chest wall. Hemostasis was ensured. First, a stab incision was made over top of the 10th rib and with the lung deflated and under direct visualization, a 28-French chest tube was inserted over top of the 10th rib and placed within the apex of the posterolateral chest. Next, #2 Polysorb sutures were used to close the thoracotomy, which was between the 10th and 11th ribs. Prior to closing the defect by tying down the sutures, the lung was reinflated and the chest tube was placed more posteriorly for good drainage. Once the ribs
were closed, the muscle wall was closed with a running 0 Polysorb suture. The deep dermis was closed with running 2-0 Polysorb suture, and the skin was closed with staples. The chest tube was secured using a 0 silk suture and this was hooked to 20 cm of continuous wall suction. An Op-Site dressing was placed over top of the incision and the chest tube was secured with a banding gun and gauze and tape. There were no complications. The patient remained intubated in
satisfactory condition in the operating room for the posterior aspect of Dr. procedure. Sponge counts were correct at the end of the case. Instruments were not counted; however, there were multiple fluoroscopic views of the entire thoracic cavity, which revealed no foreign bodies.
PREOPERATIVE DIAGNOSIS: T11-T12 compression fracture.
POSTOPERATIVE DIAGNOSIS: T11-T12 compression fracture.
PROCEDURE PERFORMED: Left lateral thoracotomy with anterior exposure of T11 and T12, with T11-12 corpectomy with cage placement and a left eleventh partial rib resection.
DISPOSITION: The patient remained intubated in stable condition for posterior portion of the procedure. The left 28-French chest tube was to low continuous suction.
HISTORY: A 73-year-old female who has been seen by Dr. for ongoing worsening back pain due to a T11-12 compression, likely due to infection. The patient is now brought to the operating room for T12-T11 corpectomy to alleviate the compression on the spinal cord. The patient was worked up by Dr.preoperatively. The patient was also seen by me preoperatively to describe the approach through the left chest wall. Risks and benefits, alternatives were discussed to her. She agreed to proceed.
REPORT OF OPERATION: After consent was obtained, the patient was brought back to the operating room. An epidural catheter was placed. The patient was then endotracheally intubated with a double-lumen ET tube and then placed in a left lateral decubitus position, secured with a beanbag. There was an axillary roll placed and the extremities were padded and secured appropriately. The C-arm was brought in and the left chest was marked. The area of the compression was noted. The
incision was planned over top of the eleventh rib, starting anterolaterally and extending around posteriorly. After this, the left chest was prepped and draped in normal sterile fashion. Prior to incision, a timeout was performed. Dr. was present as well. All team members agreed with the procedure. After placing Ioban, the thorax was incised on the left side over top of the eleventh rib with a #10 blade, deepened down through the skin and subcutaneous tissue using cautery. Overlying musculature was divided over top of the 11th rib using cautery. I then dissected into the intercostals slightly with cautery. The lung was deflated. Using a curved 6 hemostat, the intercostals were taken down, preserving the parietal pleura. A space was dissected between the pleura and the diaphragm on the left side, dissecting down
posteriorly. The lateral aspect of the vertebral bodies could be identified. In order to assist with more visualization, it was attempted to dissect the pleura off of the spine; however, there was intense inflammation in this area and the pleura was stuck. Therefore, entry was gained into the pleura with the
lung decompressed. A Finochietto rib retractor was placed to open up the space. The dissection was completed through the intercostals. Next, a periosteal elevator was used to dissect free the posterior aspect of the 11th rib. Approximately a 1-1/2 inch segment of rib was taken with rib cutters preserving the neurovascular bundle. The Finochietto rib retractor was placed again and better exposure was taken. A moistened laparotomy sponge was used to retract the lung
cephalad. We were then able to palpate the area of concern, which was inflamed. The mid portion of the T11-T12 area was incised. There was intense inflammation in this area, which was dissected, identifying the anterior aspect of the vertebral body. I then dissected through the middle of the vertebral body. There was intense cicatrix of scar tissue. Anatomy was difficult to discern. The T12 spinal artery was identified and ligated with 3-0 Prolene stick ties divided. I then dissected up to T12 and down to L1. The L1 spinal artery was preserved and dissected so that its course could be delineated. Dr. was present and it was determined that he needed more exposure cephalad. Therefore, I dissected past T11, all the way up to the inferior aspect of T10. The T11 spinal artery was also dissected and ligated using clip
applier and 3-0 Prolene stick ties. Once the anterior aspect of all the vertebral bodies were cleared off, I did use a periosteal elevator to further clear off connective tissue along the lateral aspect of the vertebral bodies. Hemostasis was ensured. At this point, Dr. was present for his portion of the procedure. Once Dr. portion was
completed and the cage with extension was inserted and confirmed to be in correct position, I was then present to close the chest wall. Hemostasis was ensured. First, a stab incision was made over top of the 10th rib and with the lung deflated and under direct visualization, a 28-French chest tube was inserted over top of the 10th rib and placed within the apex of the posterolateral chest. Next, #2 Polysorb sutures were used to close the thoracotomy, which was between the 10th and 11th ribs. Prior to closing the defect by tying down the sutures, the lung was reinflated and the chest tube was placed more posteriorly for good drainage. Once the ribs
were closed, the muscle wall was closed with a running 0 Polysorb suture. The deep dermis was closed with running 2-0 Polysorb suture, and the skin was closed with staples. The chest tube was secured using a 0 silk suture and this was hooked to 20 cm of continuous wall suction. An Op-Site dressing was placed over top of the incision and the chest tube was secured with a banding gun and gauze and tape. There were no complications. The patient remained intubated in
satisfactory condition in the operating room for the posterior aspect of Dr. procedure. Sponge counts were correct at the end of the case. Instruments were not counted; however, there were multiple fluoroscopic views of the entire thoracic cavity, which revealed no foreign bodies.