WINTER HILLS MEDICAL CENTER 753 VENTURA BYPASS • CENTRAL, FL…

MinisterFreedomCat19 WINTER HILLS MEDICAL CENTER 753 VENTURA BYPASS • CENTRAL, FL…WINTER HILLS MEDICAL CENTER 753 VENTURA BYPASS • CENTRAL, FL 32811 • 407-555-4798 PATIENT NAME: DENNING, CARTER ACCOUNT/EHR #: D018-01168594223 DATE: 10/13/18 Attending Physician: Christopher Reiersson, MD Anesthesiologist: Oscar Immolai, MD Anesthesia: General endotracheal Preoperative Diagnosis: C3 displaced spondylolisthesis Postoperative Diagnosis: Same Procedure: C3 corpectomy and fusion fixation with fibular strut graft and Atlantis plate This is a 31-year-old male status post motorcycle accident. The patient sustained a C3 displaced spondylolisthesis. 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 not limited to bleeding, infection, stroke, paralysis, death, cerebrospinal fluid (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, break or the screws could pull out. The patient provided consent. The patient was taken to the OR. The patient was induced. 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 C3 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 location using fluoroscopy. The C3 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 C3 vertebral body prior to implantation. A plate was then placed with screws in the C2 and C4 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 approximated subcuticularly. Steri-Strips applied. A dressing was applied. The patient was placed back in an Aspen collar. The patient was extubated and transferred to recovery. Christopher Reiersson, MD CR/mg D: 10/13/18 11:47:39 T: 10/14/18 09:55:36  What is the ICD-10-CM code ? What are the two PCS procedure codes?ScienceHealth ScienceNursing