hsmith67
Guru
We are currently trying to confirm correct coding - I have run this through the Codify Scrubber already - but looking to confirm nothing missed as well as modifiers that scrubber is not clear on.
Stab incision was made over the left PSIS and a stealth frame was inserted. Intraoperative CT scan was performed, images were fed into stealth and used to pan pedicle screws at L2, L4, and L5. We drilled and tapped in standard technique. L3, L4, L5 pedicle screws placed 5.5 x 50 screws at L3 and L4 and 6.5 x 45 screws at L5. Screws were placed bilaterally, and we decompressed bilaterally at L3-4, L4-5 off the medial edge of scar tissue and traced the L4 and L5 nerve roots out and performed foraminotomies. We then combined the local bone and artificial allograft and placed these in the gutters bilaterally after placing prelordosed rods with top locking screws, which were torqued appropriately. AP and lateral imaging showed appropriate placed implants prior to bone grafting. Wound had been copiously irrigated with normal saline solution. Meticulous hemostasis was obtained. Deep retractor was removed. Fascia was closed in interrupted watertight fashion. Subcutaneous layer was closed. Skin was closed with staples. Stealth frame was removed. This stab incision was closed in layers.
Thanks for any assistance in advance.
Hunter Smith, CPC
Stab incision was made over the left PSIS and a stealth frame was inserted. Intraoperative CT scan was performed, images were fed into stealth and used to pan pedicle screws at L2, L4, and L5. We drilled and tapped in standard technique. L3, L4, L5 pedicle screws placed 5.5 x 50 screws at L3 and L4 and 6.5 x 45 screws at L5. Screws were placed bilaterally, and we decompressed bilaterally at L3-4, L4-5 off the medial edge of scar tissue and traced the L4 and L5 nerve roots out and performed foraminotomies. We then combined the local bone and artificial allograft and placed these in the gutters bilaterally after placing prelordosed rods with top locking screws, which were torqued appropriately. AP and lateral imaging showed appropriate placed implants prior to bone grafting. Wound had been copiously irrigated with normal saline solution. Meticulous hemostasis was obtained. Deep retractor was removed. Fascia was closed in interrupted watertight fashion. Subcutaneous layer was closed. Skin was closed with staples. Stealth frame was removed. This stab incision was closed in layers.
Thanks for any assistance in advance.
Hunter Smith, CPC