As part of the new coding format for our newsletter, Welter Healthcare Partners is excited to offer you a new surgery coding series in which we want to help you! The 2nd week of every month we will highlight a complicated surgical case. This week we are highlighting a general surgery case. We want to hear from you! If you have a complicated surgery case and need help with coding, please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. Click Here To Submit Redacted Surgery Case StudynnPreoperative Diagnosis:n
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- Degenerative disk disease, L5-S1.
- Discognetic back pain.
- Foraminal stenosis, L5-S1.
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nPostoperative Diagnosis:n
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- Degenerative Disk disease, L5-S1.
- Discogenic back pain.
- Foraminal stenosis, L5-S1.
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nProcedure performed:n
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- Anterior lumbar discectomy, decompression of the spinal canal ad neutral foramen L5-S1.
- Anterior lumbar fusion. L5-S1.
- Application of a 12 mm intervertebral biochemical device with bone graft and BMP, L5-S1.
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nComplications: None.nnFindings: There is significant degenerative disk disease and associated collapse with L5-LS1. A thorough decompression was completed and performed with decompression of the neutral foramen and restoration of lumbar lordosis and disk space height. Final images demonstrated hardware in good position. The procedure was performed without complication through an anterior retroperitoneal approach by, this will be dictated separately.nn22612 – Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)n22614 – Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (List separately in addition to code for primary procedure)n22558 – Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbarn63047 – Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbarn22840 – Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)n22853 – Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)n61783 – Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure)n76000 – Fluoroscopy (separate procedure), up to 1-hour physician or other qualified health care professional time, other than 71023 or 71034 (eg, cardiac fluoroscopy)n20930 – Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)nM48.07 – Spinal stenosis, lumbosacral regionnM51.37 – Other intervertebral disc degeneration, lumbosacral regionnM47.817 – Spondylosis without myelopathy or radiculopathy, lumbosacral regionn