21. Provide the CPT code(s) for the following operative report from an inpatient hospital.
Operative Report
PREOPERATIVE DIAGNOSIS: Fracture/subluxation of neck, C6-7.
POSTOPERATIVE DIAGNOSIS: Fracture/subluxation of neck, C6-7.
PROCEDURE PERFORMED: Placement of halo.
ANESTHESIA: General.
PROCEDURE: Under general anesthesia, the patient’s head was prepped. The halo
was applied. The pins were secured. The vest was secured. The patient was monitored
with sensory evoked potentials. There were no changes throughout the case.
Films were done post-op, which showed the alignment was acceptable at C6-7.
CPT Code: ____________________
99396
To determine the appropriate CPT code(s) for the operative report, we need to consider the details mentioned in the report.
Based on the report, the procedure performed is the placement of a halo for the treatment of a fracture/subluxation of the neck at the C6-7 level.
The CPT code for the placement of a halo is 20661 (Application of halo, cervical), which is typically used for the initial application of a halo device. However, since the report does not mention any specific details about the type of halo used or whether it was a first-time application, it is best to consult the medical coding guidelines or speak with a certified medical coder to ensure accuracy.
Please note that this is just a general suggestion, and it is always recommended to consult with a certified medical coder or review the specific coding guidelines for accurate and up-to-date information related to medical coding.
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