Documentation Dissection - AAPC

Documentation Dissection

PREOPERATIVE DIAGNOSIS: Multiple compression fractures notably at L3, L4, and L5

Idiopathic Osteoporosis

POSTOPERATIVE DIAGNOSIS: Multiple compression fractures notably at L3, L4, and L5

Idiopathic Osteoporosis |1|

PROCEDURES:

1. L3, L4, and L5 kyphoplasty.

2. Fluoroscopic guidance |2|.

IMPLANTS: KYPHON cement.

ANESTHESIA: General endotracheal anesthesia.

INDICATIONS: This is a 58-year-old man who has multiple compression fractures of the lumbar spine and who presented with worsening of low back pain. There was no acute injury to cause these fractures. Kyphoplasties at L3, L4, and L5 were recommended. The various treatment options were discussed with the patient as well as the risks and benefits of the surgery. This is the patient's first procedure for his idiopathic osteoporosis. The patient expressed a desire to proceed with surgery and was taken to the operating room.

DETAILS OF PROCEDURE: The patient was taken to the operating room and intubated under general anesthesia. He was placed in the prone position. With AP and lateral fluoroscopy, the L3, L4, and L5 pedicles were outlined |3|. The surgical field was then prepped and draped in the standard sterile fashion. Local anesthetic with epinephrine was injected. Small stab incisions were used to incise the skin approximately of 1 cm superolateral border of the pedicle. KYPHON balloons were placed at the intravertebral body at L5. These were inflated to 2 mL on the right and 3 mL on the left with PSI of 73 and 49 respectively. Bone cement was then injected under fluoroscopy bilaterally ensuring that there was no cortical breakout. A 3 mL of bone cement were injected on the right and 3.5 mL were injected on the left |4|. Once the bone had hardened, the guide sleeves were removed. The same technique was used to inject bone cement at the L3 and L4 levels. The balloons were inflated to 2.5 mL bilaterally at L3-4 with PSI of 72 on the right and 61 on the left. A 3 mL of bone cement were then injected bilaterally at L3. At L4, the balloon was then placed at 2 mL on the right and 2.5 mL on the left with PSI values of 52 and 45 respectively. A 2 mL of bone cement were injected on the right and 2.5 mL of bone cement were injected on the left. Of note, the L5 vertebra was performed first followed by L4 and followed by L3 |5|. Final AP and lateral fluoroscopic images demonstrated no leakage of bone cement and the bone cement was also ensured to be hardened prior to removal of the guide sleeves.

The incisions were then approximated with Steri-Strips and sterile dressing was placed with Telfa and Mefix.

At the end of the case, all counts were correct x2. Dr. X was present for all critical portions of the case. The patient tolerated the procedure well, without complications, was extubated in the operating room, and was taken to PACU postoperatively in stable condition.

ESTIMATED BLOOD LOSS: 30 mL.

COMPLICATIONS: None.

_____________________________________________________________

|1| Diagnosis to report.

|2| Planned operative procedure is provided, with the spinal location

|3| Indication that fluoroscopic guidance is used.

1

|4| Insertion of the bone cement performed bilaterally on the L5 vertebral body. |5| Insertion of the bone cement performed bilaterally on L3 and L4 vertebral bodies. _____________________________________________________________ What are the CPT? and ICD-10-CM codes reported? CPT? Code: 22514, 22515 x 2 ICD-10-CM Code: M80.88XA Rationales: CPT?: The procedure header indicates the procedure performed is a kyphoplasty. Look in the CPT? Index, for Kyphoplasty, directing you to code range 22513 to 22515. It is important to note that the procedure is being completed on the vertebra, not on the vertebral interspaces. The procedure was performed on three vertebral bodies (L3, L4, and L5). Code 22514 is for the first lumbar vertebral body (L5) and add-on code 22515 is reported twice for each additional lumbar vertebral body (L3 and L4). Notice that the imaging guidance, in this case the fluoroscopy, is included in the procedure, and is not coded separately. Modifier 50 is not reported for this case because the code description already indicates it is reported when performed unilateral or bilateral. ICD-10-CM: The fracture is a compression fracture due to osteoporosis. This is not a traumatic fracture but a pathological fracture. In the Alphabetic Index look for Fracture, pathological (pathologic)/due to osteoporosis/idiopathic directing you to see Osteoporosis, specified type NEC, with pathological fracture. Look for Osteoporosis/specified type NEC/with pathological fracture/vertebra directing you to M80.88. Verification of this code in Tabular List indicates the code needs seven characters to be complete. X fills in the sixth character and for the seventh character refer back to category M80 reporting the letter A to indicate initial encounter. The complete code is M80.88XA. This code covers both the pathological fracture and osteoporosis.

2

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download