Steve Posted Fri 20th of March, 2015 08:11:36 AM
Indications for Procedure: The patient is a 69 y.o. female with a history of low back pain radiating into the right hip and leg with occasional radiation into the left leg. Imaging studies revealed L3/4 central canal calcific stenosis. Of note, she had prior spine surgery with Dr. Mcdonald years ago - there is no definitive laminectomy site on CT but the patient has a low back incision roughly centered around L5/S1. The risks, benefits, and indications for surgery were described in detail to the patient and she consented for the proposed surgery.
SuperCoder Answered Fri 20th of March, 2015 09:56:51 AM
The above information gives us the indications for the procedure, however, it does not indicates whether surgery was performed or not.
Also, AAE does not provide coding for operative reports and chart notes.
SuperCoder offers SuperCoding on Demand (SOD) (http://www.supercoder.com/coding-answers/coding-on-demand) for coding of an operative report or chart note and you can contact (866)228-9252 or e-mail email@example.com for more information.