Nicole Posted Fri 31st of May, 2013 15:08:53 PM
Can you please help with the coding of this procedure? I am not sure if it would be a 63075 or 22551 or even the 63081?
DX: Traumatic Herniated Disc C2-3
PROCEDURE IN DETAIL:
Transverse linear incision was made right at the jawline extending from the midline to just past the anterior border of the sternocleidomastoid on the right. The subcutaneous tissue was dissected through and undermined. The platysmus muscle was undermined and incised. I then created a plane between sternocleidomastoid and fascia and then between the carotid sheath and the esophagus and trachea. The longus colli muscles came into view. I then handled them by coagulating their medial edges, undermining them, and retracting them. A disk space came into view. I took a localizing x-ray with a spinal needle in that disk space and localized it to be C2-3. I then brought Cloward self retaining retractors into the wound and began the discectomy by incising the annulus with a knife and then gutting out as much disk material with pituitary rongeurs and cup curettes as was possible. At that point, when I felt I had gotten out as much as I could, I brought the Cloward drill onto the field , drilled a 12.0 mm bur hole centered at C2-3 and then I brought the microscope onto the field and completed the discectomy laterally and inferiorly with magnification. The thin cortical layer of bone at the bottom of the bur hole was removed. The herniated disk was obvious and was compressing the thecal sac severely. It was removed. However, I felt that there was a portion that penetrated the posterior longitudinal ligament so I incised and resected the posterior longitudinal ligament, found more disk material, and removed it. I then turned my attention off of the field, obtained a 24.0 mm plate and secured it to C2 and C3 with two 14.0mm variable screws at C2 and two 14.0mm fixed screws at C3. The wound was irrigated and closed with staples and dressed.
Thank you in advance!!
SuperCoder Answered Mon 03rd of June, 2013 22:12:46 PM
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