julieagus
Contributor
I really need your help. my doctor wants to bill from adjacent tissue transfer codes as well as from the Muscle myocutaneous flap. I would really appreciate if anyone would agree with his codes. Thank you so much . any opinion will be really appreciated. I copy and paste his notes as follows :
OPERATIVE REPORT
PREOPERATIVE DIAGNOSES: 1. SEVERE DOUBLE MAJOR SCOLIOSIS.
2. STATUS POST POSTEROLATERAL SEGMENTAL SPINAL INSTRUMENTATION AND FUSION FROM T4 TO L4 AFTER SURGICAL CORRECTION.
POSTOPERATIVE DIAGNOSES: 1. SEVERE DOUBLE MAJOR SCOLIOSIS.
2. STATUS POST POSTEROLATERAL SEGMENTAL SPINAL INSTRUMENTATION AND FUSION FROM T4 TO L4 AFTER SURGICAL CORRECTION.
OPERATIONS: 1. RIGHT LATISSIMUS DORSI MYOFASCIAL ADVANCEMENT FLAP. (15734)
2. LEFT LATISSIMUS DORSI MYOFASCIAL ADVANCEMENT FLAP.(15734-59)
3. BILATERAL PARASPINAL MUSCLE FLAPS (14301, 14302, 14302).
4. BILATERAL TRAPEZIAL MYOFASCIAL ADVANCEMENT. (15732)
PROCEDURE: The patient was encountered in the operating room prone on the Jackson spinal frame. The patient was under general endotracheal anesthesia and all bony prominences were well padded. The Pediatric Orthopedic Team under the direction of DrX completed the exploration, surgical correction, and posterolateral spinal instrumentation and fusion from T4 to L4.
The Plastic Surgery Team was now called into the field to provide muscle flap coverage of the operative site. We began with inspection of the area. The area had been well irrigated. Hemostasis was well controlled. Under loupe magnification, we began mobilization of the bilateral paraspinal muscle flaps. This was begun on the patient's right side.
Dissection plane was created superiorly at the level approximately T3 deep to the rhomboid complex out to the line of fusion. This dissection then continued in a superior to inferior fashion down to the pelvis. Any traversing neurovascular bundles were kept intact and not severed. Inferiorly, lateral dissection was required at the pelvis to allow sufficient medial advancement for fill of the dead space and coverage of the hardware. Medial perfusion when isolated was coagulated. Lateral segmental perfusion was kept intact. After medial advancement, inspection revealed no evidence of segmental ischemia.
We turned our attention to the contralateral paraspinal muscle mass. Again, dissection was initiated at approximately T3 where a dissection plane was created over the medial tendons out over the investing fascia out to the line of fusion. Dissection plane deep to the rhomboid complex plane and the dissection continued in a superior to inferior fashion down to the pelvis. This dissection was at the line of fusion and above the investing fascia. Any traversing neurovascular bundles were kept intact. At the pelvis, lateral dissection was required to allow sufficient medial advancement for fill of the dead space and coverage of the hardware.
Lateral segmental perfusion was kept intact. A deep #10 JP drain was secured to the skin using a 3-0 silk suture.
The bilateral paraspinal muscle masses were mobilized to the midline and secured using 0 Vicryl undyed in a figure-of-eight fashion. Intermediate space was copiously irrigated. We turned our attention now to mobilization of the right latissimus dorsi myofascial advancement flap. This was performed in standard fashion. After resection of approximately 1 cm of thoracolumbar fascia, dissection plane was created over the investing fascia out laterally. This was performed for the full extent of the incision. Dissection then proceeded with scoring release incisions from the superior border of the muscle parallel to the incision and inferiorly obliquely back to the midline. This allowed subfascial dissection, which was combined with deep dissection deep to the descending perfusion from the superior border and a medial approach. This allowed medial advancement without tension and no evidence of ischemia.
We turned our attention to mobilization of the contralateral myofascial advancement flap. After resection of the thoracolumbar fascia, dissection plane was created over the remnant fascia out laterally over the investing fascia of the muscle. This was performed for the full exposure of the incision. Dissection was taken from the superior border now with a scoring releasing incision inferiorly and parallel to the midline. This release allowed subfascial dissection, which was combined with deep dissection deep to the descending perfusion for medial advancement without tension.
Finally, the bilateral superior trapezial myofascial advancements were mobilized. These were mobilized at the dissection plane deep to the rhomboid complex. The superficial dissection was above the investing fascia out to the oblique border, which was released. The dissection continued superiorly up to the spine of the scapula where a scoring incision was made in the lateral fascia with a back-cut at the spine for medial advancement.
The bilateral latissimus dorsi myofascial advancement flaps were advanced and secured using 0 Vicryl in undyed fashion. Finally, the bilateral trapezial muscles were advanced using the combination of 0 and 2-0 undyed Vicryl in simple and figure-of-eight fashion.
Intermediate space was copiously irrigated. The final soft tissue was closed using a combination of 0 and 2-0 undyed Vicryl and then 4-0 nylon in running segments for the skin. JPs were connected to bulb suction. After wet-and-dry applications, a sterile occlusive dressing was placed. All sponge and needle counts were correct at the end of the case.
OPERATIVE REPORT
PREOPERATIVE DIAGNOSES: 1. SEVERE DOUBLE MAJOR SCOLIOSIS.
2. STATUS POST POSTEROLATERAL SEGMENTAL SPINAL INSTRUMENTATION AND FUSION FROM T4 TO L4 AFTER SURGICAL CORRECTION.
POSTOPERATIVE DIAGNOSES: 1. SEVERE DOUBLE MAJOR SCOLIOSIS.
2. STATUS POST POSTEROLATERAL SEGMENTAL SPINAL INSTRUMENTATION AND FUSION FROM T4 TO L4 AFTER SURGICAL CORRECTION.
OPERATIONS: 1. RIGHT LATISSIMUS DORSI MYOFASCIAL ADVANCEMENT FLAP. (15734)
2. LEFT LATISSIMUS DORSI MYOFASCIAL ADVANCEMENT FLAP.(15734-59)
3. BILATERAL PARASPINAL MUSCLE FLAPS (14301, 14302, 14302).
4. BILATERAL TRAPEZIAL MYOFASCIAL ADVANCEMENT. (15732)
PROCEDURE: The patient was encountered in the operating room prone on the Jackson spinal frame. The patient was under general endotracheal anesthesia and all bony prominences were well padded. The Pediatric Orthopedic Team under the direction of DrX completed the exploration, surgical correction, and posterolateral spinal instrumentation and fusion from T4 to L4.
The Plastic Surgery Team was now called into the field to provide muscle flap coverage of the operative site. We began with inspection of the area. The area had been well irrigated. Hemostasis was well controlled. Under loupe magnification, we began mobilization of the bilateral paraspinal muscle flaps. This was begun on the patient's right side.
Dissection plane was created superiorly at the level approximately T3 deep to the rhomboid complex out to the line of fusion. This dissection then continued in a superior to inferior fashion down to the pelvis. Any traversing neurovascular bundles were kept intact and not severed. Inferiorly, lateral dissection was required at the pelvis to allow sufficient medial advancement for fill of the dead space and coverage of the hardware. Medial perfusion when isolated was coagulated. Lateral segmental perfusion was kept intact. After medial advancement, inspection revealed no evidence of segmental ischemia.
We turned our attention to the contralateral paraspinal muscle mass. Again, dissection was initiated at approximately T3 where a dissection plane was created over the medial tendons out over the investing fascia out to the line of fusion. Dissection plane deep to the rhomboid complex plane and the dissection continued in a superior to inferior fashion down to the pelvis. This dissection was at the line of fusion and above the investing fascia. Any traversing neurovascular bundles were kept intact. At the pelvis, lateral dissection was required to allow sufficient medial advancement for fill of the dead space and coverage of the hardware.
Lateral segmental perfusion was kept intact. A deep #10 JP drain was secured to the skin using a 3-0 silk suture.
The bilateral paraspinal muscle masses were mobilized to the midline and secured using 0 Vicryl undyed in a figure-of-eight fashion. Intermediate space was copiously irrigated. We turned our attention now to mobilization of the right latissimus dorsi myofascial advancement flap. This was performed in standard fashion. After resection of approximately 1 cm of thoracolumbar fascia, dissection plane was created over the investing fascia out laterally. This was performed for the full extent of the incision. Dissection then proceeded with scoring release incisions from the superior border of the muscle parallel to the incision and inferiorly obliquely back to the midline. This allowed subfascial dissection, which was combined with deep dissection deep to the descending perfusion from the superior border and a medial approach. This allowed medial advancement without tension and no evidence of ischemia.
We turned our attention to mobilization of the contralateral myofascial advancement flap. After resection of the thoracolumbar fascia, dissection plane was created over the remnant fascia out laterally over the investing fascia of the muscle. This was performed for the full exposure of the incision. Dissection was taken from the superior border now with a scoring releasing incision inferiorly and parallel to the midline. This release allowed subfascial dissection, which was combined with deep dissection deep to the descending perfusion for medial advancement without tension.
Finally, the bilateral superior trapezial myofascial advancements were mobilized. These were mobilized at the dissection plane deep to the rhomboid complex. The superficial dissection was above the investing fascia out to the oblique border, which was released. The dissection continued superiorly up to the spine of the scapula where a scoring incision was made in the lateral fascia with a back-cut at the spine for medial advancement.
The bilateral latissimus dorsi myofascial advancement flaps were advanced and secured using 0 Vicryl in undyed fashion. Finally, the bilateral trapezial muscles were advanced using the combination of 0 and 2-0 undyed Vicryl in simple and figure-of-eight fashion.
Intermediate space was copiously irrigated. The final soft tissue was closed using a combination of 0 and 2-0 undyed Vicryl and then 4-0 nylon in running segments for the skin. JPs were connected to bulb suction. After wet-and-dry applications, a sterile occlusive dressing was placed. All sponge and needle counts were correct at the end of the case.