PREOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture. POSTOPERATIVE DIAGNOSIS: Painful L2 vertebral non-traumatic compression fracture.(The postoperative diagnosis is used for coding.) NAME OF OPERATION: L2 kyphoplasty.(This is the working procedure until the report is read.)

Lets add the missing piece of information for clarity

WHAT ARE THE CPT® and ICD-10-CM CODES REPORTED?

CPT® code: [a]

ICD-10-CM code: [b]

Our Answer for [a] = 22514

Our Answer for [b] = M48.56XA

Explanation:

FINDINGS PREOPERATIVELY:

She experienced compression fractures at T11 and L1 of which she had undergo kyphoplasty. She at the start had very good results but after some time, she experienced back pain like before. The need for MRI two weeks after pinpointed to the fact that she developed new high intensity signal variations in the body of L2 and few scalloping of the upper end plate, persistent with a compression fracture observed at L2.(The diagnosis is expressed in the statement of the report.) At the end of some preoperative conversations and time observing to show if she get better with time, she was taken in to the clinic for L2 kyphoplasty of which she did not get better. At surgery, L2 needed some scalloping of the upper end plate. Majority of the softness experienced happened at the back region of the vertebral body.

PROCEDURE:

The patient was admitted to the operating theatre and subjected to general endotracheal anesthesia(it is noted in the report as general anesthesia was exercised.) in a supine way. She was then positioned prone on the Jackson table with her back being prepped and draped in the regular sterile routine. Using biplane image magnifiers, the skin incision sites were noted. 0.5% amount of Marcaine with epinephrine was injected. At first on the left side. A Kyphon trocar was flown downward to the upper lateral region of the pedicle, via the pedicle, and to do the vertebral body in the regular routine.(highlights the way of attending to the defect as it percutaneous with the aid of trocars.) The drill was positioned into the vertebral body then the Kyphon bone tamp was appliednext. In a likely way, the actual process was carried out on on the other side. Balloons were inflated in the process, after which it was deflated and removed, with the cement (doughy appearance) was injected to the two positions in the general manner.(This explains the increase size of the area and the positioning of the cement in a kyphoplasty fashion.) It was carried out with care and sequentially to avoid cement extrusions at the end of inspection, it shows a good fill to the vertebral body sides, upwards in the direction of the upper end plate, and over the midline. The bone filling equipment were taken off, and the trocars were taken off too, Pressure was used later on the skin as sutured with 4-0 nylon. Sand-Aids were used and she was moved to recovery in stable situation.

COMPLICATIONS:

No observed complications.

BLOOD LOSS:

Little blood loss.

COUNTS:

Sponge and needle counts were absolutely right.

WHAT ARE THE CPT® and ICD-10-CM CODES REPORTED?

CPT® code: [a]

ICD-10-CM code: [b]

Our Answer for [a] = 22514

Our Answer for [b] = M48.56XA

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