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WESTON HOSPITAL 629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541 PATIENT: APPON, CYNTHIA ACCOUNT/EHR #: APPOCY001 Attending Physician: Regina Glasser, MD Preoperative Diagnosis: C5 compression fracture Postoperative Diagnosis: Same Procedure: C5 corpectomy and fusion fixation with fibular strut graft and Atlantis plate Anesthesia: General endotracheal This is a 31-year-old female status post assault. The patient sustained a C5 compression fracture. MRI scan showed compression with evidence of posterior ligamentous injury. The patient was subsequently set up for the surgical procedure. The procedure was described in detail, including the risks. The risks included but were not limited to bleeding, infection, stroke, paralysis, death, CSF leak, loss of bladder and bowel control, hoarse voice, paralyzed vocal cord, death, and damage to adjacent nerves and tissues. The patient understood the risks. The patient also understood that bank bone instrumentation would be used and that the bank bone could collapse and the instrumentation could fail or break, or the screws could pull out. The patient provided consent. The patient was taken to the OR. The patient was induced. An endotracheal tube was placed. A Foley was placed. The patient was given preoperative antibiotics. The patient was placed in slight extension. The right neck was prepped and draped in the usual manner. A linear incision was made over the C5 vertebral body. The platysma was divided. Dissection was continued medial to the sternocleidomastoid to the prevertebral fascia. This was cauterized and divided. The longus colli was cauterized and elevated. The fracture was visualized. A spinal needle was used to verify the location using fluoroscopy. The C5 vertebral body was drilled out. The bone was saved. The disks above and below were removed. The posterior longitudinal ligament was removed. The bone was quite collapsed and fragmented. Distraction pins were then packed with bone removed from the C5 vertebral body prior to implantation. A plate was then placed with screws in the C4 and C6 vertebral bodies. The locking screws were tightened. The wound was irrigated. Bleeding was helped with the bipolar. The retractors were removed. The incision was approximated with simple interrupted Vicryl. The subcutaneous tissue was approximated, and skin edges were approximated subcuticularly. Steri-Strips were applied. A dressing was applied. The patient was placed back in an Aspen collar. The patient was extubated and transferred to recovery. Be sure to list the codes, one code per box, in the correct sequence, from top to bottom, and in the proper row. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices. Please list modifiers with the code they relate to as necessary. Include a hyphen in between the code and the modifier. Example Procedure: 43846-74 or for Anesthesia: 00797-P2. NOTE: The CPT Changes: An Insider’s View; CPT Assistant and Clinical Examples are not considered symbols or notations for this exercise. Determine the accurate surgery CPT code(s) and modifier(s), if appropriate. The number of spaces provided does not indicate the number of codes required to accurately report this encounter.

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