574coding
Guru
Hello,
I am having problems coding this report. Does anyone have any thoughts or help on this?
We have 22852, but I do not think that is correct...This is all I have from the provider...HELP...
PREOPERATIVE DIAGNOSES:
Status post prior IA to Si fusion.
2. Hardware failure.
3. Back pain with mechanical symptoms.
POSTOPERATIVE DIAGNOSES:
1. Status post prior IA to Si fusion.
2. Hardware failure.
3. Back pain with mechanical symptoms.
OPERATIONS PERFORMED:
1. Removal of hardware. 22852
2. Exploration. 22830
3. Revision of hardware. 22845
4. Debridement of tissue.
ASSISTANT: yes
INDICATIONS: The patient has a history of prior fusion and developed hardware failure. He developed progressive mechanical type symptoms as well including the sensation of "metal on metal". Ile did have an incident of a potentially traumatic event following his surgery with sudden and this may have led to his hardware failure. In any event, we had a long talk of the
options including leaving the hardware in place etc. We did discuss that one option would he to leave the hardware in place but the metal on metal wear could result in problems. We discussed the possibility of waiting 6 months to year and then removing all of the hardware as well with exploration. After thorough discussion of the options, he wanted to proceed with the hardware
revision.
DESC'RIPT1ON OF PROCEDURE: The patient was placed prone on the Allen frame with the arms in 90:90 position and pressure points well padded. His old incision was marked and his back was perpepd and draped in usual sterile fashion. His old incision was not extended. This was used with bilateral subperiosteal dissection and the hardware easily identified and this was
delineated. This had obviously failed. This was dissembled in the standard fashion including the collars and rods. There was titanium wear debris present. I debrided all of the titanium wear debris which was visible. This was black staining of the tissues at the area where the hardware had dissembled. This was debrided with pituitaries and curettes etc. so that there was no additional wear debris. The collars were removed and inspected and appeared intact. The rods appeared intact as well. The fusion mass appeared grossly intact. This was not a copious amount of bone that had formed at this point but there was some bone forming when the fusion mass was explored.
At this point. I checked each of the screws to make sure that these had a good purchase and each of these had an excellent purchase. This was done with a screwdriver by gently applying torque to the screws to assure that these had not loosened. These indeed were intact. The tracts for the rods were made. Appropriate sized rods were used and pre-bent which were the Eminent Spine
rods. These were placed and lordorsed with the rod bender. The collar was placed and torqued to the appropriate PSI as well. This was a stable construct. Prior to placement of the rods, the screws were carefully inspected to make sure that these were intact.
One option would have been to have removed the screws and replace these. However, there would have been morbidity associated with this as well and the screws appeared completely intact. There was no evidence of any mechanical malfunction of the screws when the revision was performed. This was dry prior to closure. Bipolar was used for hemostasis. Vancomycin
powder was placed to the deep space as well with 1 gram being placed. This was irrigated at multiple points along the procedure and closed with interrupted sutures in layers and a subcuticular closure. Steri-Strips and dry dressing were placed. The patient was rolled supine, awakened, and taken in good condition to the recovery room. Estimated blood loss was 60 mL. Final sponge and needle counts were correct. Complications were none.
I am having problems coding this report. Does anyone have any thoughts or help on this?
We have 22852, but I do not think that is correct...This is all I have from the provider...HELP...
PREOPERATIVE DIAGNOSES:
Status post prior IA to Si fusion.
2. Hardware failure.
3. Back pain with mechanical symptoms.
POSTOPERATIVE DIAGNOSES:
1. Status post prior IA to Si fusion.
2. Hardware failure.
3. Back pain with mechanical symptoms.
OPERATIONS PERFORMED:
1. Removal of hardware. 22852
2. Exploration. 22830
3. Revision of hardware. 22845
4. Debridement of tissue.
ASSISTANT: yes
INDICATIONS: The patient has a history of prior fusion and developed hardware failure. He developed progressive mechanical type symptoms as well including the sensation of "metal on metal". Ile did have an incident of a potentially traumatic event following his surgery with sudden and this may have led to his hardware failure. In any event, we had a long talk of the
options including leaving the hardware in place etc. We did discuss that one option would he to leave the hardware in place but the metal on metal wear could result in problems. We discussed the possibility of waiting 6 months to year and then removing all of the hardware as well with exploration. After thorough discussion of the options, he wanted to proceed with the hardware
revision.
DESC'RIPT1ON OF PROCEDURE: The patient was placed prone on the Allen frame with the arms in 90:90 position and pressure points well padded. His old incision was marked and his back was perpepd and draped in usual sterile fashion. His old incision was not extended. This was used with bilateral subperiosteal dissection and the hardware easily identified and this was
delineated. This had obviously failed. This was dissembled in the standard fashion including the collars and rods. There was titanium wear debris present. I debrided all of the titanium wear debris which was visible. This was black staining of the tissues at the area where the hardware had dissembled. This was debrided with pituitaries and curettes etc. so that there was no additional wear debris. The collars were removed and inspected and appeared intact. The rods appeared intact as well. The fusion mass appeared grossly intact. This was not a copious amount of bone that had formed at this point but there was some bone forming when the fusion mass was explored.
At this point. I checked each of the screws to make sure that these had a good purchase and each of these had an excellent purchase. This was done with a screwdriver by gently applying torque to the screws to assure that these had not loosened. These indeed were intact. The tracts for the rods were made. Appropriate sized rods were used and pre-bent which were the Eminent Spine
rods. These were placed and lordorsed with the rod bender. The collar was placed and torqued to the appropriate PSI as well. This was a stable construct. Prior to placement of the rods, the screws were carefully inspected to make sure that these were intact.
One option would have been to have removed the screws and replace these. However, there would have been morbidity associated with this as well and the screws appeared completely intact. There was no evidence of any mechanical malfunction of the screws when the revision was performed. This was dry prior to closure. Bipolar was used for hemostasis. Vancomycin
powder was placed to the deep space as well with 1 gram being placed. This was irrigated at multiple points along the procedure and closed with interrupted sutures in layers and a subcuticular closure. Steri-Strips and dry dressing were placed. The patient was rolled supine, awakened, and taken in good condition to the recovery room. Estimated blood loss was 60 mL. Final sponge and needle counts were correct. Complications were none.