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Bertolotti's syndrome

Dawn Posted Thu 07th of January, 2016 11:10:57 AM

Need help on selecting a CPT code please.

DX: Bertolotti's syndrome Q76.49
Procedure: Bertolotti decompression/takedown

Patient placed prone. Small 3 cm incision was made just over the SI joint and sacral ala, carried down through the fascia, and then muscle splitting technique was utilized to identify the sacral ala and junction of the transverse process. The Bertolotti's malformation wrapped around the ventral side of her sacral ala and I was concerned that I would have to take a significant amount of sacral ala down to completely remove the pseudoarticulation; however was able to identify the medial and lateral borders of the L5 transverse process and using a bur and kerrisons take down with about a centimeters width.I was able to identify transverse process and sacral ala and move them independently, identifying that there were no connections them remaining.I bone waxed the exposed cancellous bone to ensure no recurrence.I closed the fascia with # 1 vicryl, skin with 2-0 vicryl and 4-0 monocryl.

Would a osteotomy code be appropriate here?

SuperCoder Answered Fri 08th of January, 2016 01:48:43 AM

AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) ( for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail for more information.

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