Wiki Spinal Instrumentation

[bethanne46]

How do you know if an anterior plate is a standalone plate or integrated? Do you depend on the surgeon to say that? Are there clues in the body of the note?

 

[amyjph]

If you have access to the hospital record you can check the hardware and instrumentation logs they have the manufacturer, etc. "Usually" the implants are stated in the header of the op note. It's good feedback to suggest the provider states that specifically to improve their documentation. It's hard to tell otherwise. Some providers have an instrumentation preference and only use stand alone. You can ask them to document what they used if you can't tell from the op note, otherwise you really cannot accurately code it.