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Q&A Need help coding this case

Nancy Swope

New Member
PREOPERATIVE DIAGNOSES:
1. Lumbar spinal stenosis.
2. Lumbar spondylolisthesis.
POSTOPERATIVE DIAGNOSES:
1. Lumbar spinal stenosis.
2. Lumbar spondylolisthesis.
PROCEDURE:
1. L4-5 bilateral laminoforaminotomies.
2. L4-5 transforaminal lumbar interbody fusion.
3. L4-5 posterolateral fusion with segmental instrumentation.
4. Placement of local bone autograph.
5. Placement of crushed cancellous allograft and DBX.
6. Small kit of InFuse.

DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room. A time out process
was undertaken with the patient awake, alert, and oriented. She
was then placed supine on our standard Jackson operating room
table. She underwent general anesthesia by the Anesthesia staff.
Lower extremity SCDs were applied. A Foley catheter was placed.
She was then carefully turned with the use of the Jackson table
in a prone position. All bony surfaces were well padded. The
arms were placed in the up position. The low lumbar region was
then prepped with the use of a Betadine scrub brush, alcohol
wash, and chlorhexidine-prep sponge. It was then draped in a
sterile fashion. 30 mL of lidocaine and Marcaine were injected
in the wound prior to making incision. An incision was made over
the L4-5 level. Dissection was carried down to the fascia. The
fascia was incised in line with the incision. Paraspinal muscles
were resected out laterally exposing the transverse processes of
L4 and L5 bilaterally. Self-retaining retractor was placed. A
lateral C-arm image was taken to ensure the level of our surgery
after which time pedicle screws were placed bilaterally at L4 and
L5 from the DePuy EXPEDIUM set of appropriate size and length.
The technique was to find a starting hole with the bur, finding
the pedicle with an awl, feeling, tapping, then placing a screw
of appropriate size and length bilaterally at L4 and L5. The
pedicle screws were then stimulated and deemed to be appropriate.
This was followed by doing a laminoforaminotomy on the left side
with the use of rongeurs, Kerrisons, curettes, and a bur,
removing the inferior portion of the L4 lamina and superior
portion of the L5 lamina. The intervening ligamentum was also
sharply excised. The L5 nerve root was decompressed in its
entirety. Our attention then turned to the right side. At that
point a complete facetectomy was performed with rongeurs,
Kerrisons, curettes, and a bur. The exiting L4 nerve root was
visualized and decompressed in its entirety. The L4-5 nerve root
was also visualized. The dural sac was retracted medially with
the use of a Scoville retractor. The disk space was incised with
the use of a 15 blade. Discectomy was performed with Kerrisons,
curettes, and shavers. A complete discectomy was performed.
This was followed by thorough irrigation of the interbody disk
space. A small sponge of InFuse was then placed anteriorly.
This was followed by placement of a lateral interbody spacer from
the DePuy cougar latter interbody system. The cage itself was
filled with another InFuse sponge and local bone autograft and
allograft. It was then impacted and rotated into the proper
position. Posterior to the cage a combination of local bone
autograft and allograft was then also impacted posterior to the
cage as well to obtain a fusion across L4-5 in the interbody
space. Rods of appropriate length were placed bilaterally. Set
screws were placed and torque tightened appropriately. Slight
compression was applied across the L4-5 level. Final AP and
lateral x-rays were taken to ensure the placement of all the
instrumentation was in line with the lumbar spine. The wound was
thoroughly irrigated. All bony surfaces on the left side were
decorticated. A combination of local bone autograft and
allograft was packed in the posterolateral gutters from L4-5 on
the left side to obtain a posterolateral fusion. A subfascial
drain was placed. A gm of vancomycin powder was placed
underneath and above the fascia. The fascia was then closed with
#1 Vicryl, subcutaneous tissue was closed with 2-0 Vicryl, and
the skin was closed with a running 3-0 Biosyn suture. Sterile
dressing was applied consisting of Bactroban ointment,
Steri-Strips, 4 x 4, and Tegaderm. She was then carefully turned
supine, extubated, and transferred to recovery in stable
condition. A gm of vancomycin powder was utilized underneath and
above the fascia. In addition, 60 mL of 0.25% Marcaine were
injected underneath the fascia for postoperative pain control.
Dr. Lance Mitsunaga, M.D., was scrubbed and assisted for the
entire case. Neuromonitoring was used throughout this case and
there was no change from preoperative to postoperative.
 
J

jacobgabriel

Guest
Hi., I have some question in these what is difference between PREOPERATIVE DIAGNOSES and POSTOPERATIVE DIAGNOSES ? Any major distinguish between these two.?
 

Alicia Scott

Moderator, CCO Instructor
Staff member
Administrator
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Blitzer
PBC Student (CPC®)
CCO Club Member
CCO Support Staff
MTA Student
ICD-10-CM Student
PPM Student (CPPM®)
FBC Student (CPC-H®)
Some time there is no change but if they get in there and look around it can change. Also, a pathology report can change a diagnosis from say a mass to a malignancy/benign tumor.
 
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