katz0813
Contributor
Hi,
I have never coded a surgery with a co-surgeon before. Could someone please look at this and let me know if I an correct. I am coding for DR. YYYYY.
Codes I am using are: 22558,62 22845,59 22853 w/2 units 22585,62
Much appreciated!!
DR. YYYYY OP-NOTES:
DESCRIPTION OF PROCEDURE:
Please see Dr. XXXXX dictation for the details of the approach, inspection at the end, and closure.
Once the patient had L4-5 and L5-S1 appropriately dissected free, we started at the L5-S1 disk space. With appropriate retraction of the soft tissues, an annulotomy was performed. A Cobb elevator was used under fluoroscopic guidance to release disk and endplate cartilage from endplate bone. Pituitary rongeur was used to release and remove the soft tissue. Angled curettes were used to release further disk material and endplate cartilage until a full preparation of the L5-S1 disk space had been performed. A trial expander was placed under fluoroscopic guidance to guide this to the most posterior aspect of the L5-S1 disk space. Expansion was performed and we were able to release the osteophyte at this level. There were no changes in neural monitoring.
The distractor was removed. We, again, prepared the endplates to ensure bone was exposed at L5-S1. We used a medium kit of bone morphogenic protein and used 1/2 of this at the L5-S1 disk space into our cage. The cage was placed under fluoroscopic guidance and expanded until the torque mechanism released. X-ray showed the cage to be in acceptable position with acceptable alignment of the lumbar spine and restoration of lordosis. We used the drill and 4 screws placing 2 in the S1 segment and 1 in the L5 segment at the L5-S1 level. 25 mm screws were placed. The locking mechanisms were secured. X-ray showed acceptable alignment of the lumbar spine with acceptable position of all of our instrumentation. There were no changes in neural monitoring.
We then performed the same procedures at L4-5 as was performed at L5-S1. Full disk prep was performed prior to expanding and then preparing again the endplate and then placing our cage with the other half of bone morphogenic protein. 30 mm screws were used at this level of L4 and L5. Final mechanism was secured. Final x-ray showed acceptable alignment of the lumbar spine with acceptable position of all of our instrumentation. There were no sponges left and fluoroscopic views were taken to ensure this.
Please see DR. XXXXX dictation for the remainder of the closure for this surgery.
Sterile dressings were placed. The patient was extubated and transferred to the postanesthesia care in good condition. DR. YYYYY was present for the entirety of the case except for closure. All sponge and needle counts were correct at the end the case.
============================================
DR. XXXXX OP-NOTES:
DESCRIPTION OF PROCEDURE: I was present as the patient was brought to the operating room, there for the time- outs. After intubation and Foley placement, the abdomen was prepped and draped Ãin the usual sterile fashion. Time-out was repeated. I made a longitudinal incision from just above the pubic symphysis just on the left side of midline up towards the umbilicus. I dissected through subcutaneous tissue with electrocautery onto the fascia. I made a paramedian incision in the fascia, seeing the rectus abdominus. This was rotated laterally, and then, in the most inferior portion, I did a blunt dissection intothe retroperitoneal space. As I did this, I identified the ureter and brought that up and towards the right side, bluntly dissecting the retroperitoneal space, and eventually saw the left external iliac moving proximally onto the common iliac, hypogastric, and the distal aorta. I again kept rotating, bluntlydissecting. No peritoneal injury was noted. Self-retaining special retractor was placed. We began at the L5-S1 disk space. This was done between the great vessel bifurcation, and I sharply dissected along the left common iliac vein andtowards the right common iliac artery, freeing the sacral space. We identified the L5-S1 disk space, and I was able to mobilize the vessels laterally, medially, and also superiorly inferior for enough space that Dr. YYYYY could do his procedure. I placed retractors, was present as he did his L5-S1 disk procedure. After this, we were good with hemostasis. We then turned to the L4-L5 disk space. In order to approach this, I went lateral to the left common iliac artery and the aorta, rotating that laterally towards the right side. As we did that, there were large crossing vessels, which were clipped, eventually getting a good exposure of the L4-L5 disk space. This was mobilized proximally and distally. We localized this with a needle, and then Dr. YYYYY proceeded with an L4-L5 disk procedure. Upon completion, again no vascular injury noted. We irrigated, reinspected for any injury. We removed our retractors. We did lateral and AP views and also cleared the abdomen of any instruments or sponges. Then, I closed the fascia with #1 PDS superiorly inferior, running 3-0 Vicryl in the subcutaneous tissue and 4-0 Monocryl subcutaneous.
I have never coded a surgery with a co-surgeon before. Could someone please look at this and let me know if I an correct. I am coding for DR. YYYYY.
Codes I am using are: 22558,62 22845,59 22853 w/2 units 22585,62
Much appreciated!!
DR. YYYYY OP-NOTES:
DESCRIPTION OF PROCEDURE:
Please see Dr. XXXXX dictation for the details of the approach, inspection at the end, and closure.
Once the patient had L4-5 and L5-S1 appropriately dissected free, we started at the L5-S1 disk space. With appropriate retraction of the soft tissues, an annulotomy was performed. A Cobb elevator was used under fluoroscopic guidance to release disk and endplate cartilage from endplate bone. Pituitary rongeur was used to release and remove the soft tissue. Angled curettes were used to release further disk material and endplate cartilage until a full preparation of the L5-S1 disk space had been performed. A trial expander was placed under fluoroscopic guidance to guide this to the most posterior aspect of the L5-S1 disk space. Expansion was performed and we were able to release the osteophyte at this level. There were no changes in neural monitoring.
The distractor was removed. We, again, prepared the endplates to ensure bone was exposed at L5-S1. We used a medium kit of bone morphogenic protein and used 1/2 of this at the L5-S1 disk space into our cage. The cage was placed under fluoroscopic guidance and expanded until the torque mechanism released. X-ray showed the cage to be in acceptable position with acceptable alignment of the lumbar spine and restoration of lordosis. We used the drill and 4 screws placing 2 in the S1 segment and 1 in the L5 segment at the L5-S1 level. 25 mm screws were placed. The locking mechanisms were secured. X-ray showed acceptable alignment of the lumbar spine with acceptable position of all of our instrumentation. There were no changes in neural monitoring.
We then performed the same procedures at L4-5 as was performed at L5-S1. Full disk prep was performed prior to expanding and then preparing again the endplate and then placing our cage with the other half of bone morphogenic protein. 30 mm screws were used at this level of L4 and L5. Final mechanism was secured. Final x-ray showed acceptable alignment of the lumbar spine with acceptable position of all of our instrumentation. There were no sponges left and fluoroscopic views were taken to ensure this.
Please see DR. XXXXX dictation for the remainder of the closure for this surgery.
Sterile dressings were placed. The patient was extubated and transferred to the postanesthesia care in good condition. DR. YYYYY was present for the entirety of the case except for closure. All sponge and needle counts were correct at the end the case.
============================================
DR. XXXXX OP-NOTES:
DESCRIPTION OF PROCEDURE: I was present as the patient was brought to the operating room, there for the time- outs. After intubation and Foley placement, the abdomen was prepped and draped Ãin the usual sterile fashion. Time-out was repeated. I made a longitudinal incision from just above the pubic symphysis just on the left side of midline up towards the umbilicus. I dissected through subcutaneous tissue with electrocautery onto the fascia. I made a paramedian incision in the fascia, seeing the rectus abdominus. This was rotated laterally, and then, in the most inferior portion, I did a blunt dissection intothe retroperitoneal space. As I did this, I identified the ureter and brought that up and towards the right side, bluntly dissecting the retroperitoneal space, and eventually saw the left external iliac moving proximally onto the common iliac, hypogastric, and the distal aorta. I again kept rotating, bluntlydissecting. No peritoneal injury was noted. Self-retaining special retractor was placed. We began at the L5-S1 disk space. This was done between the great vessel bifurcation, and I sharply dissected along the left common iliac vein andtowards the right common iliac artery, freeing the sacral space. We identified the L5-S1 disk space, and I was able to mobilize the vessels laterally, medially, and also superiorly inferior for enough space that Dr. YYYYY could do his procedure. I placed retractors, was present as he did his L5-S1 disk procedure. After this, we were good with hemostasis. We then turned to the L4-L5 disk space. In order to approach this, I went lateral to the left common iliac artery and the aorta, rotating that laterally towards the right side. As we did that, there were large crossing vessels, which were clipped, eventually getting a good exposure of the L4-L5 disk space. This was mobilized proximally and distally. We localized this with a needle, and then Dr. YYYYY proceeded with an L4-L5 disk procedure. Upon completion, again no vascular injury noted. We irrigated, reinspected for any injury. We removed our retractors. We did lateral and AP views and also cleared the abdomen of any instruments or sponges. Then, I closed the fascia with #1 PDS superiorly inferior, running 3-0 Vicryl in the subcutaneous tissue and 4-0 Monocryl subcutaneous.