jdibble
True Blue
Hopefully I can get some help with this surgery. It was billed to insurance and denied by the payer saying the codes billed are not supported by the documentation. If someone could please tell me what codes are wrong and what they should be I would really appreciate it! I can't see where I went wrong and think I may have even missed coding some codes now that I reviewed it! The codes I billed are 22633, 63052, 63053, 22840, 22853, 20937. None of these were paid.
OPERATION PERFORMED:
1. L3-4 Transforaminal lumbar interbody fusion with combined L3-4 posterolateral arthrodesis.
2. Decompression beyond that required for a TLIF including facetectomies and foraminotomies.
3. Placement of posterior nonsegmental instrumentation spanning L3-4.
4. Preparation of endplates and placement of Innovasis interbody cage L3-4.
5. Utilization of local bone autograft for interbody and posterolateral arthrodesis.
6. Use of intraoperative fluoroscopy for determination of levels and hardware placement.
7. Harvest of Iliac crest bone graft for implantation
8. Use of morcelized allograft for implantation
9. Central decompression L2-3
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. General endotracheal anesthesia was induced without complication. IV antibiotics were administered prior to incision. Time-out was commenced prior to surgery to confirm the procedure and appropriate levels. A Foley catheter was placed without complication. Patient was then placed prone on the Jackson frame. All bony prominences were well padded. The patient's eyes remained pressure free during the entirety of this case. The patient's back was prepped and draped in the usual sterile fashion. 133 mg of Exparel and 30 cc of 0.5% Marcaine were injected subcutaneously at the site of incision and paraspinal muscles for local pain relief.
A midline lumbar incision was made from the L2 to the L4 level with a 10-blade scalpel. Bleeding was controlled with Bovie cautery. We went down through previous scar from his prior incisions. Sharp dissection was carried down through the lumbodorsal fascia. Subperiosteal elevation of the paraspinal musculature was carried out over the spinous process of L3, with exposure of the lamina and facet joints bilaterally at L3-4. At L2-3 we only went out to the midportion of the facet and left the facet capsules intact at these levels as a posterolateral fusion and instrumentation was not planned for these segments. I then confirmed my level with fluoroscopy. I decorticated the transverse processes of L3 and L4 as well as denuding the facet capsule of L3-4 to facilitate my posterolateral fusion.
I land marked an appropriate trajectory for my pedicle screws and burred a hole at the junction of the transverse process and the facet. I then probed tapped and inserted my pedicle screws in the L3 and L4 vertebra bilaterally. AP and lateral fluoroscopy confirmed appropriate positioning of the implants. The pedicle screws were stimulated with a neuromonitoring probe. All pedicle screws stimulated above acceptable threshold levels. The left L3 stimulated above 20 milliamps, the right L3 stimulated above 20 milliamps, the left L4 stimulated above 20 milliamps, and the right L4 stimulated above 20 milliamps.
After confirming my levels. I performed a central decompression at L2-3 by using a rongeur to resect the interspinous ligament and the caudal portion of the spinous process of L2. I took a portion of the cephalad part of L3. I used the microscope for this portion of the case. I used a 3 mm high-speed bur to bur down the medial and caudal half of the lamina and facet. I burred up into the foramina and lateral recess while leaving the ligamentum flavum intact to protect the nerve. I burred down the leading edge of the lamina of L3 as well. I used an angled curette to release ligamentum flavum from the facet and lamina. I resected the ligamentum flavum with a Kerrison rongeur from the midline out towards the lateral recess. I used straight and angled Rogers to undercut the foramina and open up L2 and L3. I carried this down through the lateral recess such that I was then able to pass a probe freely into the foramina of L2 and L3. At the leading edge of L3 I placed a angled probe against the dura to retract it so that it did not impinge while resecting the leading edge of L3. I did this both in the ipsilateral and contralateral side. I obtained hemostasis with FloSeal and ultimately placed a Gelfoam pledget over the exposed dura.
My findings from the decompression were as follows.: At L2-3 there was primarily facet tropism which resulted in a very sagittally oriented facet. We would to frequently assess her bone stock to ensure that we did not resect significant facet bone. As such we had to undercut the foramina and lateral recess as opposed to resecting from dorsal to ventral..
I then performed bilateral facetectomies at L3 level. I used a 2 mm bur to bur a trough in the lamina adjacent to the spinous process base and across the pars at the level of the disc space. I then completed the break in the bone with an osteotome separating the inferior facet of L3 from the pars. This was resected en block. I used Kerrison rongeurs to then resect the remaining portion of the L4 facet and decompress the foramina and lateral recess resecting ligamentum flavum and exposing the exiting and transiting nerve root. This decompression was a separate-and-distinct portion of the procedure. Given the patient's preoperative history of stenosis, it was necessary to resect the facet joints bilaterally, as well as to perform complete foraminotomies bilaterally to alleviate the compression on the traversing L4 nerve roots as well as the exiting L3 nerve roots. The decompression procedure was performed in addition to the normal decompression required for the transforaminal lumbar interbody fusion. Prior to decompression, the nerve probe met resistance in the lateral recesses and foramen. After decompression, the nerve probe passed easily into the lateral recesses and foramen without residual stenosis.
The local bone from the laminectomy site was processed and morselized. It was used later in the case for the interbody arthrodesis as well as the posterolateral arthrodesis.
I turned my attention to the right iliac crest and made a separate incision over the PSIS. I dissected down through subcutaneous tissue and identified the iliac crest. I stripped it down to bleeding bone. I then inserted the gym she had a trocar needle into the iliac crest and aspirated 10 mL of bone marrow aspirate for implantation. I then broached the crest and used a combination of reamers and curettes to harvest iliac crest cancellous bone from between the 2 tables without violating the inner or outer table of the pelvis. This bone was placed in the interbody cage and disc space to facilitate our fusion. Hemostasis was obtained and this incision was ultimately closed at the end of the case.
At this point, the transforaminal lumbar interbody fusion was carried out. Posts were placed into the tulips of the pedicle screws at L 3 and 4 and tightened to eliminate the poly axial head. A distractor was placed across the post and distraction was performed.. Distraction was performed across the disk space. This was 1st done on the contralateral side to the TLIF during the facetectomy to aid in the decompression. The traversing L 4 nerve root was was freed from underlying disc and gently retracted medially with a nerve root retractor. An annulotomy was performed at the L 3 4 level with an 11-blade scalpel.
Next, a series of shavers were placed into the disk space to remove additional disk material as well as to decorticate the endplates of L4 and L5 as the interbody arthrodesis was carried out. Straight and upbiting pituitaries were utilized to remove the disk material.
Next, straight and angled curettes were used to further decorticate the endplates of L4 and L5, as the interbody arthrodesis was carried out.
Next, a trial interbody spacer was placed. After determination of the correct size interbody spacer, morselized local autologous bone graft was placed into the anterior disk space followed by insertion of the interbody cage which was filled with iliac crest bone graft. The cage was turned perpendicular and into the coronal plane. Additional bone graft including iliac crest, and demineralized bone matrix were placed behind the cage in the disc space. At this point, distraction was released from the posts in order to load the graft in the disc space.
At this point, rods were contoured into lumbar lordosis and placed into the tulips of the pedicle screws from L4 through L5 bilaterally. The end caps were tightened to the appropriate end-torque values. The L4 vertebra was reduced to the rod via the Tulip screws and then compressed to L5 before final tightening. All hardware was tightened to a final torque.
The wound was then copiously irrigated with normal saline. A Gelfoam pledget was placed over the exposed dura. I inspected the nerve roots to ensure that no bone graft was impinging upon the roots.
The posterolateral arthrodesis was then carried out. A combination of local bone autograft and remaining allograft was placed into the bilateral posterolateral gutters at L3-4 to complete the posterolateral arthrodesis at this level....
Thank you for any and all help on this one!
Jodi
OPERATION PERFORMED:
1. L3-4 Transforaminal lumbar interbody fusion with combined L3-4 posterolateral arthrodesis.
2. Decompression beyond that required for a TLIF including facetectomies and foraminotomies.
3. Placement of posterior nonsegmental instrumentation spanning L3-4.
4. Preparation of endplates and placement of Innovasis interbody cage L3-4.
5. Utilization of local bone autograft for interbody and posterolateral arthrodesis.
6. Use of intraoperative fluoroscopy for determination of levels and hardware placement.
7. Harvest of Iliac crest bone graft for implantation
8. Use of morcelized allograft for implantation
9. Central decompression L2-3
DESCRIPTION OF PROCEDURE: The patient was taken to the operating room. General endotracheal anesthesia was induced without complication. IV antibiotics were administered prior to incision. Time-out was commenced prior to surgery to confirm the procedure and appropriate levels. A Foley catheter was placed without complication. Patient was then placed prone on the Jackson frame. All bony prominences were well padded. The patient's eyes remained pressure free during the entirety of this case. The patient's back was prepped and draped in the usual sterile fashion. 133 mg of Exparel and 30 cc of 0.5% Marcaine were injected subcutaneously at the site of incision and paraspinal muscles for local pain relief.
A midline lumbar incision was made from the L2 to the L4 level with a 10-blade scalpel. Bleeding was controlled with Bovie cautery. We went down through previous scar from his prior incisions. Sharp dissection was carried down through the lumbodorsal fascia. Subperiosteal elevation of the paraspinal musculature was carried out over the spinous process of L3, with exposure of the lamina and facet joints bilaterally at L3-4. At L2-3 we only went out to the midportion of the facet and left the facet capsules intact at these levels as a posterolateral fusion and instrumentation was not planned for these segments. I then confirmed my level with fluoroscopy. I decorticated the transverse processes of L3 and L4 as well as denuding the facet capsule of L3-4 to facilitate my posterolateral fusion.
I land marked an appropriate trajectory for my pedicle screws and burred a hole at the junction of the transverse process and the facet. I then probed tapped and inserted my pedicle screws in the L3 and L4 vertebra bilaterally. AP and lateral fluoroscopy confirmed appropriate positioning of the implants. The pedicle screws were stimulated with a neuromonitoring probe. All pedicle screws stimulated above acceptable threshold levels. The left L3 stimulated above 20 milliamps, the right L3 stimulated above 20 milliamps, the left L4 stimulated above 20 milliamps, and the right L4 stimulated above 20 milliamps.
After confirming my levels. I performed a central decompression at L2-3 by using a rongeur to resect the interspinous ligament and the caudal portion of the spinous process of L2. I took a portion of the cephalad part of L3. I used the microscope for this portion of the case. I used a 3 mm high-speed bur to bur down the medial and caudal half of the lamina and facet. I burred up into the foramina and lateral recess while leaving the ligamentum flavum intact to protect the nerve. I burred down the leading edge of the lamina of L3 as well. I used an angled curette to release ligamentum flavum from the facet and lamina. I resected the ligamentum flavum with a Kerrison rongeur from the midline out towards the lateral recess. I used straight and angled Rogers to undercut the foramina and open up L2 and L3. I carried this down through the lateral recess such that I was then able to pass a probe freely into the foramina of L2 and L3. At the leading edge of L3 I placed a angled probe against the dura to retract it so that it did not impinge while resecting the leading edge of L3. I did this both in the ipsilateral and contralateral side. I obtained hemostasis with FloSeal and ultimately placed a Gelfoam pledget over the exposed dura.
My findings from the decompression were as follows.: At L2-3 there was primarily facet tropism which resulted in a very sagittally oriented facet. We would to frequently assess her bone stock to ensure that we did not resect significant facet bone. As such we had to undercut the foramina and lateral recess as opposed to resecting from dorsal to ventral..
I then performed bilateral facetectomies at L3 level. I used a 2 mm bur to bur a trough in the lamina adjacent to the spinous process base and across the pars at the level of the disc space. I then completed the break in the bone with an osteotome separating the inferior facet of L3 from the pars. This was resected en block. I used Kerrison rongeurs to then resect the remaining portion of the L4 facet and decompress the foramina and lateral recess resecting ligamentum flavum and exposing the exiting and transiting nerve root. This decompression was a separate-and-distinct portion of the procedure. Given the patient's preoperative history of stenosis, it was necessary to resect the facet joints bilaterally, as well as to perform complete foraminotomies bilaterally to alleviate the compression on the traversing L4 nerve roots as well as the exiting L3 nerve roots. The decompression procedure was performed in addition to the normal decompression required for the transforaminal lumbar interbody fusion. Prior to decompression, the nerve probe met resistance in the lateral recesses and foramen. After decompression, the nerve probe passed easily into the lateral recesses and foramen without residual stenosis.
The local bone from the laminectomy site was processed and morselized. It was used later in the case for the interbody arthrodesis as well as the posterolateral arthrodesis.
I turned my attention to the right iliac crest and made a separate incision over the PSIS. I dissected down through subcutaneous tissue and identified the iliac crest. I stripped it down to bleeding bone. I then inserted the gym she had a trocar needle into the iliac crest and aspirated 10 mL of bone marrow aspirate for implantation. I then broached the crest and used a combination of reamers and curettes to harvest iliac crest cancellous bone from between the 2 tables without violating the inner or outer table of the pelvis. This bone was placed in the interbody cage and disc space to facilitate our fusion. Hemostasis was obtained and this incision was ultimately closed at the end of the case.
At this point, the transforaminal lumbar interbody fusion was carried out. Posts were placed into the tulips of the pedicle screws at L 3 and 4 and tightened to eliminate the poly axial head. A distractor was placed across the post and distraction was performed.. Distraction was performed across the disk space. This was 1st done on the contralateral side to the TLIF during the facetectomy to aid in the decompression. The traversing L 4 nerve root was was freed from underlying disc and gently retracted medially with a nerve root retractor. An annulotomy was performed at the L 3 4 level with an 11-blade scalpel.
Next, a series of shavers were placed into the disk space to remove additional disk material as well as to decorticate the endplates of L4 and L5 as the interbody arthrodesis was carried out. Straight and upbiting pituitaries were utilized to remove the disk material.
Next, straight and angled curettes were used to further decorticate the endplates of L4 and L5, as the interbody arthrodesis was carried out.
Next, a trial interbody spacer was placed. After determination of the correct size interbody spacer, morselized local autologous bone graft was placed into the anterior disk space followed by insertion of the interbody cage which was filled with iliac crest bone graft. The cage was turned perpendicular and into the coronal plane. Additional bone graft including iliac crest, and demineralized bone matrix were placed behind the cage in the disc space. At this point, distraction was released from the posts in order to load the graft in the disc space.
At this point, rods were contoured into lumbar lordosis and placed into the tulips of the pedicle screws from L4 through L5 bilaterally. The end caps were tightened to the appropriate end-torque values. The L4 vertebra was reduced to the rod via the Tulip screws and then compressed to L5 before final tightening. All hardware was tightened to a final torque.
The wound was then copiously irrigated with normal saline. A Gelfoam pledget was placed over the exposed dura. I inspected the nerve roots to ensure that no bone graft was impinging upon the roots.
The posterolateral arthrodesis was then carried out. A combination of local bone autograft and remaining allograft was placed into the bilateral posterolateral gutters at L3-4 to complete the posterolateral arthrodesis at this level....
Thank you for any and all help on this one!
Jodi