I'm trying to code this op note where the dr did a posterolateral decompression fusion at L4-5 over a year ago and had to go back in due to adjacent level stenosis. Here's an excerpt from the note:
At this point we took we took our attention to the right iliac crest. We incised with cautery, the fascia over the iliac crest using the same initial incision, and we were able to take down the cortical bone followed by the cancellous bone using a #4 curette. Once we were able to take all the cancellous bone that was available to us here, we were able to put SurgiFlo in the bone donor site and then use Gelfoam followed by closure of the fascia overlying the iliac crest. Thereafter our attention was back to the wound where we were able to remove the hardware including the rod and the screws, and we were able to replace them with HA-coated screws. The size was maintained to be the same. At this point our attention was taken to the decompression at L4-5 followed by full laminectomy and bilateral foraminotomy, medial facetectomy at L3-4. Once this was completed, we were able to put our rods back on at the L4-5 level, use the BMP. Once the rods were placed, we were able to put the set screws on top, get final x-rays that ascertained that we were in the right position, and that everything looked appropriate, and we were able to break off the set screws, put some Vancomycin powder over the hardware and after placement of the Infuse in the gutters as well as iliac crest bone graft and MagniFuse on both sides. We were able to then close the dorsolumbar fascia and use a drain superficially to the dorsolumbar fascia following closure of it with #1 Vicryl and closure of the subcutaneous tissue with a #2 Vicryl and closure of the skin with #2 nylon. The wound was dressed in a standard sterile fashion and then the patient was placed in a supine fashion after she awoke from anesthesia, she was taken to recovery.
I came up w/22830, 22852, 22850, 22849-51, 63047-59-51 and 20936. My question is can I code 22830 w/22850 & 22852 and if so, do I append modifiers? Any assistance would be greatly appreciated! Thanks, M
At this point we took we took our attention to the right iliac crest. We incised with cautery, the fascia over the iliac crest using the same initial incision, and we were able to take down the cortical bone followed by the cancellous bone using a #4 curette. Once we were able to take all the cancellous bone that was available to us here, we were able to put SurgiFlo in the bone donor site and then use Gelfoam followed by closure of the fascia overlying the iliac crest. Thereafter our attention was back to the wound where we were able to remove the hardware including the rod and the screws, and we were able to replace them with HA-coated screws. The size was maintained to be the same. At this point our attention was taken to the decompression at L4-5 followed by full laminectomy and bilateral foraminotomy, medial facetectomy at L3-4. Once this was completed, we were able to put our rods back on at the L4-5 level, use the BMP. Once the rods were placed, we were able to put the set screws on top, get final x-rays that ascertained that we were in the right position, and that everything looked appropriate, and we were able to break off the set screws, put some Vancomycin powder over the hardware and after placement of the Infuse in the gutters as well as iliac crest bone graft and MagniFuse on both sides. We were able to then close the dorsolumbar fascia and use a drain superficially to the dorsolumbar fascia following closure of it with #1 Vicryl and closure of the subcutaneous tissue with a #2 Vicryl and closure of the skin with #2 nylon. The wound was dressed in a standard sterile fashion and then the patient was placed in a supine fashion after she awoke from anesthesia, she was taken to recovery.
I came up w/22830, 22852, 22850, 22849-51, 63047-59-51 and 20936. My question is can I code 22830 w/22850 & 22852 and if so, do I append modifiers? Any assistance would be greatly appreciated! Thanks, M