Chapter 14: Application Practice
64493-50
M51.36 - Answer PREOPERATIVE DIAGNOSES:
1. LOW BACK PAIN.
2. DEGENERATIVE LUMBAR DISC.
POSTOPERATIVE DIAGNOSES:
1. LOW BACK PAIN.
2. DEGENERATIVE LUMBAR DISC.
PERFORMED: Bilateral Paravertebral facet joint injection of steroid at the L3-L4 and L4-L5 with
fluoroscopic guidance.
DESCRIPTION OF PROCEDURE: The patient was transferred to the operative suite and placed in
the prone position with a pillow under the abdomen. A smooth IV sedation was given with
midazolam and fentanyl. The patient's back was prepped with Betadine in a sterile fashion, and
we used lidocaine, 1% plain as a local anesthetic at the injection site. With the use of
fluoroscopic assistance, first to the right and then to the left 20-degrees, the scotty-dog view
was identified, and we were able to place the spinal 22-gauge needle, first to the right L3-L4,
then to the right L4-L5, then to the left L3-L4, and then to the left L4-L5. We used a lateral x-ray
to assess the proper placement of the needle. We proceeded to inject a mixture of 4 ml of
0.25% Marcaine plain plus 80 mg of methylprednisolone divided between the four joints. The
needles were removed. The patient's back was cleaned, and a Band-Aid was applied. The
patient was transferred to the recovery area with no apparent procedural complications.
What are the CPT® and ICD-10-CM codes reported?
61322
I61.9 - Answer OPERATION PERFORMED: Right-sided decompressive hemicraniectomy with
duraplasty.
COMPLICATIONS: None.
, ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Approximately 400 ml
INDICATIONS: is a 56 year-old male with significant past medical history who came in this
evening with an ischemic infarct to his right MCA territory which converted to hemorrhagic
transformation. The significant shift was following commands on the right side and hemiplegia
on the left side. After a thorough discussion with the family, we explained to them that this
would be a life-saving procedure and we could not ensure that there would be any further
neurological improvement from the state that he was in. They understood these risks and
wanted to proceed ahead.
OPERATION PERFORMED: After informed consent was obtained, the patient was taken to the
operating room and induced under general endotracheal anesthesia without incident. TEE
monitor was placed due to the patient's significant cardiac history. At this point, a roll was
placed underneath the right shoulder and the head was placed in a horseshoe reverse question
mark. This area was sterilely prepped and draped in usual fashion. A #10 blade was used to
make an incision sharply. Raney clips were applied to the skin edges. The temporalis fascia and
muscle were then resected with the cutaneous flap anteriorly. This was done until the keyhole
could be identified. The musculocutaneous flap was then retracted with towel hooks, rubber
bands and Allis clamps. The perforator was then used to make several burr holes (approximately
six) and a footplate was then applied to perform the hemicraniectomy. We ensured that we
were off midline to make certain that we did not get into the sagittal sinus or any draining veins
associated with this. Once the bone was removed, hemostasis was obtained, t
63685
T85.113A - Answer PREOPERATIVE DIAGNOSIS: Dorsal column stimulator generator
malfunction.
POSTOPERATIVE DIAGNOSIS: Dorsal column stimulator generator malfunction.
PROCEDURE PERFORMED: Replacement of dorsal column stimulator generator.
ATTENDING: John Smith, MD
ANESTHESIA: Monitored anesthetic coverage with local.
ESTIMATED BLOOD LOSS: Less than 5 ml
SPECIMENS: None.
64493-50
M51.36 - Answer PREOPERATIVE DIAGNOSES:
1. LOW BACK PAIN.
2. DEGENERATIVE LUMBAR DISC.
POSTOPERATIVE DIAGNOSES:
1. LOW BACK PAIN.
2. DEGENERATIVE LUMBAR DISC.
PERFORMED: Bilateral Paravertebral facet joint injection of steroid at the L3-L4 and L4-L5 with
fluoroscopic guidance.
DESCRIPTION OF PROCEDURE: The patient was transferred to the operative suite and placed in
the prone position with a pillow under the abdomen. A smooth IV sedation was given with
midazolam and fentanyl. The patient's back was prepped with Betadine in a sterile fashion, and
we used lidocaine, 1% plain as a local anesthetic at the injection site. With the use of
fluoroscopic assistance, first to the right and then to the left 20-degrees, the scotty-dog view
was identified, and we were able to place the spinal 22-gauge needle, first to the right L3-L4,
then to the right L4-L5, then to the left L3-L4, and then to the left L4-L5. We used a lateral x-ray
to assess the proper placement of the needle. We proceeded to inject a mixture of 4 ml of
0.25% Marcaine plain plus 80 mg of methylprednisolone divided between the four joints. The
needles were removed. The patient's back was cleaned, and a Band-Aid was applied. The
patient was transferred to the recovery area with no apparent procedural complications.
What are the CPT® and ICD-10-CM codes reported?
61322
I61.9 - Answer OPERATION PERFORMED: Right-sided decompressive hemicraniectomy with
duraplasty.
COMPLICATIONS: None.
, ANESTHESIA: General endotracheal.
ESTIMATED BLOOD LOSS: Approximately 400 ml
INDICATIONS: is a 56 year-old male with significant past medical history who came in this
evening with an ischemic infarct to his right MCA territory which converted to hemorrhagic
transformation. The significant shift was following commands on the right side and hemiplegia
on the left side. After a thorough discussion with the family, we explained to them that this
would be a life-saving procedure and we could not ensure that there would be any further
neurological improvement from the state that he was in. They understood these risks and
wanted to proceed ahead.
OPERATION PERFORMED: After informed consent was obtained, the patient was taken to the
operating room and induced under general endotracheal anesthesia without incident. TEE
monitor was placed due to the patient's significant cardiac history. At this point, a roll was
placed underneath the right shoulder and the head was placed in a horseshoe reverse question
mark. This area was sterilely prepped and draped in usual fashion. A #10 blade was used to
make an incision sharply. Raney clips were applied to the skin edges. The temporalis fascia and
muscle were then resected with the cutaneous flap anteriorly. This was done until the keyhole
could be identified. The musculocutaneous flap was then retracted with towel hooks, rubber
bands and Allis clamps. The perforator was then used to make several burr holes (approximately
six) and a footplate was then applied to perform the hemicraniectomy. We ensured that we
were off midline to make certain that we did not get into the sagittal sinus or any draining veins
associated with this. Once the bone was removed, hemostasis was obtained, t
63685
T85.113A - Answer PREOPERATIVE DIAGNOSIS: Dorsal column stimulator generator
malfunction.
POSTOPERATIVE DIAGNOSIS: Dorsal column stimulator generator malfunction.
PROCEDURE PERFORMED: Replacement of dorsal column stimulator generator.
ATTENDING: John Smith, MD
ANESTHESIA: Monitored anesthetic coverage with local.
ESTIMATED BLOOD LOSS: Less than 5 ml
SPECIMENS: None.
