AUDIT REPORT T14.2 OPERATIVE REPORT, LAMINOTOMIES

Essay

AUDIT REPORT T14.2 OPERATIVE REPORT, LAMINOTOMIES
AND FORAMINOTOMIES
The physical status is 1. Anesthesia by: MDA and CRNA. Anesthesiologist was medically directing 4 concurrent cases.
PREOP NOTE: This patient has been counseled regarding his disc, regarding the inability to relieve his pain, the necessity for further surgery, fusion, the complications of persistent pain, pseudomeningocele, and infection. He consents to go ahead with surgery because of the intractable pain.
DESCRIPTION OF PROCEDURE: Under general anesthesia the patient was placed in prone position. The back was prepped and draped in the usual manner. An incision was made in the skin extending through the subcutaneous tissue, lumbdorsal fascia divided. The erector spini muscles were bluntly dissected from the lamina of L3-4, the interspace was localized via x-ray. I then performed a generous laminotomy, foraminotomy and looked at the L3-4 disc space laterally. There was a hole in the annulus. We entered the disc space and then removed much degenerating material medially and laterally, took it down with curets, took it down with various pituitary rongeurs, and cleaned out the disc space. Irrigated the wound well. Then closed the wound in layers utilizing double-knotted 0 chromic on the lumbdorsal fascia with O Vicryl and 2-0 plain in the subcutaneous tissue and surgical staples on the skin and dressing was applied. The patient was discharged to the recovery room.
One of the following modifiers is incorrectly reported for this case. Indicate the modifier that is incorrect.
T14.2:
PHYSICIAN CODE: 00630-QY-P1_______________________________________
CRNA CODE: 00630-QX-P1____________________________________________
INCORRECT MODIFIER: ______________________________________________