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Traumatic C7-T1 bilateral locked/jumped facet with a fracture

Mary ann Posted Tue 23rd of July, 2013 22:23:48 PM

My physician performed an open reduction of C7-T1 locked facet (fracture) after performing a laminectomy at C7-T1, then performed anterior cercial discectomy and fusion C7-T1 using screws, plate and cage, then went back and did the posterior cervical thoracic fusion C5-T2 using lateral mass screws, pedicle screws and rods. I used 22326, 22554-51, 22845, 22851, 22600-51, 22614, 22614, 22842, 63045-51, 63048. I wasn't sure if I could or should code the laminectomy (63045) with the reduction code (22326) or even if that is the right code for the open reduction of the locked facet. The pt. hit a bump in the road and she flew up and hit the roof of the car with her head resulting in severe flexion of her neck. MRI showed severe subluxation of C7-T1 with bilateral jump facet. She also suffers from severe central canal stenosis and cord compression resulting in myelopathy. Thanks

SuperCoder Answered Fri 26th of July, 2013 00:06:43 AM

The coding of this complex case is:
22326 (lami is included at C7 and T1 levels, so 63045/48 not separately reportable)

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