Gina Posted Mon 12th of November, 2018 20:05:26 PM
Need help and confirmation that this is a minimally invasive procedure based on documentation below and do not meet the open arthrodesis approach. Since DTRAX system is used for minimally invasive procedure, should this be coded 0219T which includes the fusion, foraminotomy, instrumentation, cage and bone graft?
Doctor’s Listed procedure: Posterior cervical foraminotomy and fusion using the Dtrax and Cavux system
Dr’s Codes: 22600, 22614, 22840, 22853, and 20930
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and after uneventful anesthetic induction and intubation wasrotated prone onto a foam chest and shoulder harness, bolsters andfoam head pillow. All her pressure points were checked. The head of the bed was cocked down two notches of the foot up a few degrees and then the chest started straps were secured to the distal end of the table to provide traction. Her head was then taped mid position onto the table so there would not be any movement. We then brought in the lateral C-arm and using a variety of techniques, we were able to get a good projection of the C6-C7 level, identifying the C7 spinous process by the small calcification within the nuchal ligaments, posterior nuchal ligaments just dorsal to the C6 spinous process. Once we had obtained the good lateral projection, the AP C-arm was brought into position and it was maneuvered until we had a good AP projection. Then, using a K wire, the midline spinous processes and the medial and lateral aspect of the facet joints were marked on her skin on either side approximating the C6-C7 and C5-C6 level trend transversely. Once that was accomplished, the back of her head and neck were sterilely prepped and draped in the usual fashion and then a sterile spinal needle was introduced into the patient's right side where, I anticipated the skin incision for the planned trajectory would occur. A lateral intraoperative film was obtained showing that this indeed would provide a good approach to the C6-C7 facet joints. This was then marked transversely across the facet marking and a vertical incision was created at the midline of the facet markings on the right side and left side. Once that was accomplished, a surgical pause was observed and then the skin was recently infiltrated with 0.25% Marcaine with epinephrine along of the deep soft tissues on either side. Starting on the right hand side a #10 knife was used to create the skin incision using Bovie coagulating cautery to open up the cervical dorsal fascia and then a muscle splitting a blunt dissection technique was used with
the deep tracks access chisel to approach C6-C7 identified an lateral projections and the mid position of the facet joint identified on AP projections. Counting and confirming our levels
several times and satisfied that we were approaching C6-C7. The access chisel was advanced with a mallet until it docked on the pedicle. Checking this again in AP and lateral projections to make sure, we were at the mid position of the facet joint. We then introduced the guide tube over the access chisel, which was then withdrawn. The facet joint was decorticated dorsally with a decorticator and then the facet joint itself was decorticated using a rasp and screw type to decorticator. A EVO3 CAVUX cage was carefully tapped into the right C6-C7 facet joint without difficulty. Once that was confirmed radiographically, it is being in proper position. The set screw was locked in place. The dorsal surface of the facet joint was then packed with EVO3 and the guide tube withdrawn. AP and lateral films were taken to confirm good positioning of the device. The left side was accomplished in the same fashion making the skin incision with a #10 knife using blunt dissection down to
the left C6-C7 facet joint with the access chisel and then advancing the access chisel. Once it was positioned over the facet joint using a mallet. Once access to the wounds in place, the dorsal surface of the facet joint was decorticated and then the guide tube was introduced over the access chisel. Once it was docked the access chisel was withdrawn and then the facet joint itself was
decorticated with a rasp and a screw type brought decorticator. Once that was accomplished a second CAVUX cage packed with EVO3 was introduced into the left C6-C7 facet joint, once it was seated properly. The locking screw was secured. The dorsal surface of the facet joint was then packed with EVO3 and then the guide tubes were withdrawn.
SuperCoder Answered Tue 13th of November, 2018 01:27:01 AM
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 firstname.lastname@example.org for more information.