Charles Posted Wed 30th of May, 2012 17:06:30 PM
How to code the following: Posterior decompressive laminectomy, total, C5, C6 and C7 with bilateral foraminotomies C5-6, C6-7 and C7-T1 also resection of epidural phlegmon and drainage of epidural pus. Preoperative/Postoperative - Diagnosis Cervical Epidural Abscess
Im thinking of the following: 63045,63048,63048-however I'm not capturing the phlegmon resection and drainage. Please advise-any assistance would be greatly appreciated.
Operative Findings: Purulent fluid drained out bewteen C5-6 and C6-7, and a s,maller amount from C7-T1 interlamonar space once the paraspinous muscles were retracted apart. Gram stain showed inflammatory cells but no definite organisms. Multiple cultures were sent, and tissue was sent for histopathologic examination. Frozen section was consistent with acute inflammation consistent with abscess.
placed in the prone position on chest rolls with her head held fixed in a 3 point Mayfield headrest. The posterior neck was trimmed of hair and then prepped in the usual manner. The skin was infiltrated with local anesthetic. An incision was make sharply extending from the spinous process of C4 down to C7-T1 spinous area. The ligamentum muchae was divided in the midline. Then subperiostral dissection was carried out along the lateral border of the spinous process of C4 down to T1 and extended over the respective lamina. Identification of C5 down to C7 spinous processes was confirmed with intraoperative fluroscopy. Then, spinous process of C5 through C7 was removed. Then, using a high-speed drill, a total laminectomy of C5 down through C7 was carried out with good decompression fot the spinal canal. The lateral border of the lamina was trimmed laterally until there was adequate decompression of the spinal sac. A generous foraminotomy was carried out at C5-6, C6-7 and C7-T1 on both sides with removal of the epidural phlegmon. This was particularly more pronounced on the right side than the left. Once the phlegmon was removed, spontaneous pulsation was seen in the spinal sac. Once we were sure tht there was adequate room fot the nerve toors as they exited from the spinal canal, especially on the right side, then the would was irrigated with copious amounts of antibiotic normal saline solution. All bleeding was controlled. Small strips of thrombin-soaked Gelfoam were laid along the bony gutter of the spinal canal to maintain good hemostasis. Then a 7 mm flat JP drain was laid over the eopdural space and tunneled to exit through a separate stab would in the skin and connected to a sterile vacuum suction bulb. The wound was then closed in laters using interrupted Victyl sutures to reapproximate the paraspinous muscle, and then interrupted O Prolene to reapproximate the deep fascia and ligamentum nuchae, and interrupted 3-0 mylon to close the skin.Sterile occlusive dressing was applied. No complication were encountered. The patient tolerated the procedure without any difficulty.
SuperCoder Answered Thu 31st of May, 2012 09:04:27 AM
You are right to report 63045, 63048, and 63048. These are the appropriate codes for the given scenario.
Rational: Phlegmon is the acute suppurative inflammation affecting the subcutaneous connective tissue. Simply when infectious Cystic pus/material spread outside and infects the epidural space, called as epidural phlegmon.
When removal and/or drainage of infection, phlegmon or cyst is performed with the major procedures like laminectomy, foraminectomy etc, the same would be inclusive and not be reported separately for the same anatomical level.