dimanche 23 août 2015

Spine Coding Assistance Please

I am new at spine coding and am wondering if someone could help me code this procedure. I am not sure if you would need the entire operative report or if the list of procedures would suffice. This is a staged procedure and has knocked me off my socks.

Thank you so much!!
Denise

STAGE ONE

PREOPERATIVE DIAGNOSIS:
1. Right L2-L3 foraminal stenosis, with right L2-L3 radiculopathy.
2. Lumbar degenerative scoliosis, with advanced right L2-L3
degenerative disc disease and an asymmetric disk collapse on the
right.

POSTOPERATIVE DIAGNOSIS:
1. Right L2-L3 foraminal stenosis, with right L2-L3 radiculopathy.
2. Lumbar degenerative scoliosis, with advanced right L2-L3
degenerative disc disease and an asymmetric disk collapse on the
right.

PROCEDURE PERFORMED: This is a 2-stage procedure, stage 1 of 2.
1. Anterior interbody fusion through a right lateral approach, L2-L3.
2. Placement of prosthetic interbody device, Choice Spine dolphin
cage, L2-L3, size 45 mm x 17 mm x 6-degree lordotic.
3. Use of bone graft substitute, Vitoss, mixed with cancellous chips.
4. Use of bone marrow aspirate through a separate incision.




STAGE TWO
PREOPERATIVE DIAGNOSES:
1. Right L2-L3 foraminal stenosis, severe with right L2 and L3
radiculopathy.
2. Lumbar degenerative scoliosis with asymmetric disk collapse, right
L2-L3, and severe degenerative changes.

POSTOPERATIVE DIAGNOSES:
1. Right L2-L3 foraminal and lateral recess stenosis with right L2
and L3 radiculopathy.
2. Lumbar degenerative scoliosis with severe degenerative disc
disease at L2-L3 and right L2-L3 severe disc collapse.

PROCEDURE PERFORMED: This is a 2-stage procedure, stage 2 of 2:
1. Posterior lumbar fusion L2-L3.
2. Posterior nonsegmental instrumentation pedicle screws, Stryker
Xia, bilateral L2-L3, size 4.5 mm x 45 mm at both levels.
3. Use of bone graft substitute Vitoss and cancellous chips.
4. Right-sided foraminotomy and facetectomy, L2-L3.


Spine Coding Assistance Please

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