Case -AUDIT REPORT T12.1 OPERATIVE REPORT, RE-DO LAMINOTOMY

Essay

Case
-AUDIT REPORT T12.1 OPERATIVE REPORT, RE-DO LAMINOTOMY
General
LOCATION: Inpatient, Hospital
PATIENT: Sarah Malone
ATTENDING PHYSICIAN: Timothy Pleasant, MD
SURGEON: Timothy Pleasant, MD
PREOPERATIVE DIAGNOSIS: Herniation of L4-5 on the right
POSTOPERATIVE DIAGNOSIS: Herniation of L4-5 on the right
PROCEDURE PERFORMED: Re-do laminotomy, foraminotomy, L4-5 on the right
ANESTHESIA: General
PROCEDURE: Under general anesthesia, the patient was placed in the prone position. The back was prepped and draped in the usual manner. An incision was made extending through subcutaneous tissue. The lumbodorsal fascia was divided. The erector spinae muscles were bluntly dissected from the lamina of L4-5. The L4-5 interspace was localized via x-ray. We enlarged the laminotomy and foraminotomy, saw the extruded fragment, and removed it. We entered the disc space and removed much degenerating material. We decompressed the nerve root, satisfied there were no other free fragments. I irrigated the wound well. I put a Hemovac drain in the wound and closed the wound in layers utilized double-knotted 0 chromic on the lumbodorsal fascia, 0 Vicryl and 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. A dressing was applied. The patient was discharged to the recovery room.
PATHOLOGY REPORT LATER INDICATED: Intervertebral disc fragments, L4-L5
T12.1:
SERVICE CODE(S): 63030_________________
ICD-10-CM DX CODE(S): M51.9___________
INCORRECT/MISSING CODE(S): ________________________________________