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Sample CPC Exam Question 2: Musculoskeletal

OPERATIVE NOTE

PREOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.

POSTOPERATIVE DIAGNOSIS: myelopathy secondary to very large disc herniations at C4-C5 and C5-C6.

PROCEDURE PERFORMED:

1. Anterior discectomy, C5-C6

2. Arthrodesis, C5-C6

3. Partial corpectomy, C5

4. Machine bone allograft, C5-C6

5. Placement of anterior plate with a Zephyr C6

ANESTHESIA: General

ESTIMATED BLOOD LOSS: 60 mL

COMPLICATIONS: None

INDICATIONS: This is a patient who presents with progressive weakness in the left upper extremity as well as imbalance. He has a very large disc herniation that came behind the body at C5 as well and as well as a large disc herniation at C5-C6. Risks and benefits of the surgery including bleeding, infection, neurologic deficit, nonunion, progressive spondylosis, and lack of improvement were all discussed. He understood and wished to proceed.

DESCRIPTION OF PROCEDURE:

The patient was brought to the operating room and placed in the supine position. Preoperative antibiotics were given. The patient was placed in the supine position with all pressure points noted and well padded. The patient was prepped and draped in standard fashion. An incision was made approximately above the level of the cricoid. Blunt dissection was used to expose the anterior portion of the spine with carotid moved laterally and trachea and esophagus moved medially. I then placed needle into the disc spaces and was found to be at C5-C6. Distracting pins were placed in the body of C6. The disc was then completely removed at C5-C6. There was very significant compression of the cord. This was carefully removed to avoid any type of pressure on the cord. This was very severe and multiple free fragments noted. This was taken down to the level of ligamentum. Both foramen were then also opened. Part of the body of C5 was taken down to assure that all fragments were removed and that there was no additional constriction. The nerve root was then widely decompressed. Machine bone allograft was placed into C5-C6 and then a Zephyr plate was placed in the body C6 with a metal pin placed into the body at C5. Excellent purchase was obtained. Fluoroscopy showed good placement and meticulous hemostasis was obtained. Fascia was closed with 3-0 Vicryl, subcuticular 3-0 Dermabond for skin. The patient tolerated the procedure well and went to recovery in good condition.

a. 22554, 63081, 63082, 20931, 22845

b. 22551, 63081, 20931, 22840

c. 22551, 63081, 63082, 20931, 22845

d. 22554, 63081, 20931, 22840

Rational:

Answer: A

Per. Paul Cadorette and the American Medical Association article titles, “Coding Guidance for Anterior Cervical Arthrodesis”, “When a spinal fusion (arthrodesis) is performed, the first thing a coder needs to recognize is the approach or technique that was utilized. With an anterior (front body approach)to cervical fusion the incision will be made in the patient’s neck, so the key terms to look for are platysma, esophagus, carotid, and sternocleidomastoid. These structures will be divided and/or protected during dissection down the vertebral body. After dissection, the procedure can proceed on one of three ways:

1) When the interspace is prepared (minimal discectomy, perforation of endplates) then 22554 would be reported.

2) When a discectomy is performed to decompress the spinal cord and/or nerve root(s) report 22554 for the arthrodesis along with 63075 for the discectomy procedure.

3) When a partial corpectomy (vertebral body resection) is performed at C5 and C6 report CPT code 22554 for the arthrodesis with 63081 and 63082. Two codes are reported because the corpectomy procedure is performed on two vertebral segments (C5 and C6). CPT codes 63081-63091 include a discectomy above and/or below the vertebral segment, so code 63075 (discectomy) would not be reported if performed at the C5-C6 interspace.

Once the decompression procedure has been completed, a PEEK cage can be placed within the interspace or a structural bone graft can be fashioned to fit the vertebral defect created by the previous corpectomy. Insertion of the PEEK cage would be reported with a biomechanical device code 22851. This code is only reported one time per level even if two cages are placed at C5-C6. When a structural bone graft is used, determine whether it is an allograft (20931)) or an autograft (20938). The bone graft codes are only reported one time per procedure and not once for each level. Finally, the physician will place an anterior plate with screws (22845) across the C5-C6 interspace to stabilize the area fusion”.

Some guidance on coding such procedures can also be located in the Spine (vertebral column) coding guidelines (above code 22010).

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By: Katherine Dawson, Certified Professional Coder

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