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Orthopedic Coding

Medical Posted Wed 08th of April, 2015 11:31:48 AM

Please assist with coding CPT and DX for the note below. Thank you.

Procedure performed
1. Microscopic anterior cervical discectomy at C5-C6 for purposes of decompressing the spinal canal, the spinal cord and the neurologic structures.
2.c5-c6 anterior interbody fusion using distraction arthodesis technique
3.Insertion of the Peek cage at c5c6
4. Anterior stabilization at c5-c6 using a contoured plate
5. Use a Gardner Wells tongs
6. Use of local bone graft
7. Intraoperative use of flueroscopy

Procedure: Under general anesthesia with endotracheal intubation the pt was placed in the supine position on the jackson spine table. Neck was prepped and draped in the usual manner. Gardner wells tongs were placed. He was placed with 5 pounds of axial traction. A transverse incision was made on the left side of the neck. This was carried down through the skin and the subcutaneous tissue. Dissection was carried to the anterior sternocleidomastoid muscle and anterior to the carotid sheath. Once this was positively identified the longus coli muscles were elevated and a cottle type retractor was inserted. The c5-c6 level was identified. The anterior protruding osteophytes were removed with a high-speed burr. The annulus was incised with a knife and the disc was removed with pituitary rongeurs. Distraction posts were placed in C5 and c6 and the interspace was further distracted. The microscope was pulled into position. Using the operating microscope, the disc was removed back to posterior longitudinal ligament. A high speed burr was used to removed the posterior protruding osteophytes.
A 1mm foraminotomy kerrison was used to perform bilateral foraminotomies take down the posterior longitudinal ligament, remove the middle protrusion and decompress the spinal canal and neurologic structures. Hemostasis was then achieved. Bacterin sponge soaked with blood and local bone was harvested of the end plates. The Bacterin sponge was then packed into the cage. It was 8mm high and 10 degree angled. Cage was gently tapped into position under fluoroscopic control ans direct vision. Distraction was then removed. Distraction posts were removed. A plate was contoured and then applied to the spine using two screws in the body. C5 and two in the body of C6. All screws were appropriately torqued. Hemostasis was achieved. The esophagus was inspected. It was noted to be atraumatic. The wound was then closed in layers with 2-0 for paltysma and 4-0 for subcuticular closure. Sterile dressings were applied. The patient was taken to the recovery room and judged to be in stable condition and neurologically intact.

Pre and post opt diagnosis
C5-C6 Herniated nucleus pulposus
C5-C6 retrolisthesis
C5-C6 Kyphotic deformity

SuperCoder Answered Thu 09th of April, 2015 01:22:41 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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