CASE 12-16 Operative Report. Hele Vest Placement and Repair The Pow erport There e procese wwwwwwwwwwww new barrere www And the

CASE 12-16 Operative Report. Hele Vest Placement and Repair The Pow erport There e procese wwwwwwwwwwww new barrere www And the NEB MPSC SUV nya FREETIMESES Oras the device WILSON tram SEHEN 1 Hiki w 3D CVC wewe AESTHESMO DATNE NOTE The powe r CASE 12-16 Operative Report, Halo Ve Now here is a case to challenge your coding abilities. Reference the “Procedure Performed” section of the report to identify the number of procedures to be coded, noting that there are two segments to report for the fixation and fusion. Then read the report and ensure that the procedures are those identified in the “Procedure Performed” section. Assume this is the initial care of this fracture. There will be a CPT for the fracture treatment arthrodesis, autograft, skeletal fixation, cranial halo, and the evoked potentials. Assign a diagnosis code for the fracture and an external cause for the fracture circumstances. LOCATION: Inpatient, Hospital PATIENT: Tim Brent ATTENDING PHYSICIAN Timothy Pleasant, MD SURGEON Timothy Pleasant, MD PREOPERATIVE DIAGNOSIS: Unstable C5 (fifth cervical vertebral fracture with spinal deformity and upper extremity weakness POSTOPERATIVE DIAGNOSIS: Unstable CS fracture with spinal deformity and upper extremity weakness PROCEDURE PERFORMED 1. Halo vest placement 2. Posterior segmental fixation C4 through Cs with Halifax clamps 3. Open correction of cervical fracture 4. Posterior cervical fusion C4 through C6 using bone autograft and right iliac crest graft 5. Evoked potential monitoring of upper extremity ANESTHESIA: General endotracheal anesthesia OPERATIVE NOTE: The patient was taken to the operating room and placed under general endotracheal anesthesia. This was done SE 12-17 Operative Report, Discec CHAPTER 12 do Vest Placement and Repair nice the beroptically. On com o was then placed in a four b at the chil intuition, the neorical traction using standard technique after e st This was done maintaining on chest rolls. The posteri Celical region tral posto Surrounding the best i test w well as the area in the usual stanie manner The W hen cod and draped This was done t a t h at was hestend in a generous amount of cancellene the spilt thickness graftw. then closed ininterrupted harved The wound s h posterior cervical region was then inced Sharp dissection was carried had been the out through the subcutaneous The subperiosteal dissection was undertaken from we e d and a through C Great care was utilized to avoid stripping the muscle from to minimize any chance of incorporating growing fusion at these levels and C7 in an attempt The superior aspect of the hemilamina of CA and the inferior aspect of the hemilamina of C were then carefully exposed using our Halifax clamps were then fashioned and secured from C4 through C5 The area of CS was noted to be fractured in multiple places including the facet joints bilaterally and the lamina. The Halifax clamo construct was then assembled un ventfully and was noted to be secure The Lamina was then decorticated with a cutting burr, and the cancellous and cortical bones were utilized to complete the posterior cervical fusion Halifax clamping ensured proper correction of the slight cervical deformity and throughout the procedure, the evoked potential monitoring electrodes placed on the scalp electrically stimulate nerves and results are recorded and reported separately was noted to be normal. Hemostasis was then ensured. The wound was closed in interrupted layers with staples for the skin SERVICE CODES) ICD-10-CM DX CODES) ectory

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