Brooke DiBell
Musculoskeletal Coding Assignment
SCENARIO 1
Pre-op Diagnosis: multilevel C spine degenerative disc disease, with upper extremity radiculopathy.
neck pain, cervicalgia and chronic pain syndrome
Post-op diagnosis: same as pre-op dxs
Procedure: Cervical epidural steroid injection, level C6/C7 via midline approach with fluoroscopy and
epidurogram
Anesthesia: local anesthesia with IV sedation per Anesthesia department due to complications
associated with anxiety and low pain threshhold due to complications associated with severe chronic
pain.
Procedure: 18 gauge, 3 1/2 inch Tuohy epidural needle advanced via midline approach until cervical
epidural space identified. Confirmation of needle placement identified. Epidurogram performed which
showed excellent spread of contrast solution one segment above and one segment below tip of needle
placement.
120mg of Depo-Medrol and 4cc preservative free normal saline injected into cervical epidural space
without complications. Needle removed. Bandaid was placed over puncture site.
You need to complete:
1. Diagnosis codes____M51.15,M54.2, M54.2,G89.4
2. PCS code____3EOR3KZ, BR10ZZZ, BR00ZZ1
3. CPT code____01991, 77002, 62323, 72040_________
SCENARIO 2
Preop diagnosis: Severe osteoporosis with spontaneous L2 vertebral fracture
Postop diagnosis: same as preop dx
Procedure description: Percutaneous vertebroplasty with fluroscopic guidance
History of present illness: 56 yr old woman with severe age-related osteoporosis and a spontaneous L2
vertebral fracture conrimed with an xray. Having failed conservative management, she was brought to
the operating room for percutaneous vertebroplasty.
Description procedure: Patient placed in prone position on padded rolls and was administered
intravenous sedation. The lumbar region was prepped and draped in a standard fashion. Utilizing
fluoroscopic control, the pedicles of L2 were identified bilaterally. One the left side, a spinal needle was
used for determining the correct entry point into the vertebra after the skin had been infiltrated with
2cc of 1% Xylocaine with Epinephrine.
The needle was advanced down to the entry point, and more anesthesia was injected into the periosteal
region. Then the cannula was introduced down through the same tract after a stab incision had been
made in the skin with an 11 blade. The cannula was advanced into the vertebra with good fluroscopic
guidance in both the AP and lateral planes, in a similar fahion, the cannula on the right side was
introduced down into the vertebral body.
The methyl methacrylate was mixed appropriately and injected down into the vertebra with good filling
achieved on both the left and right sides. The cannulas were removed and the skin edges were
reapproximated with Steri-Strips. The wound was drerssed with dry gauze and Op-site dressing. Counts
were correct. Blood loss was negligible and the patient awoke from sedation and was transfewrred to
recovery in stable conditon.
Dx codes___________M80.88, M84.48__________________________________________
PCS codes ________0PU33JZ_____________________________________________
CPT code ____________25510__________________________________________
