Surgical Procedures Form

Cervical

Patients Name_____________________________________ Birth Date_______________ Surgery Date ________________

DX:________________________________________________ CPT:______________________________________________

First Assist: Monica Hart Yes No Anna Marshall: Yes No

Cervical Fusion
□ Spinal Fusion- Cervical Posterior □ Anterior Cervical Discectomy Fusion
□ Laminectomy- Micro Cervical Discectomy Posterior □ Laminectomy- Posterior Cervical

Codes Anterior Cervical

Post Cervical Fusion □ 22551- Arthrodesis- cervical below C2
□ 63045- First Level □ 63075- Cervical Discectomy
□ 63048- Additional Level □ 22551- Open Anterior Arthrodesis
□ 22600- arthrodesis C1-C2 □ 22554- Minimal Anterior Arthrodesis
□ 22614- each additional segment □ 22552- each additional space
□ 22842- posterior segmental instrumentation (3-6 □ 22845- anterior instrumentation; 2-3 segments
segments) □ 22853- biomechanical device
□ 69990- operating microscope □ 69990- Operating microscope
□ 20936- autograft: local □ 20936- autograft, local
□ 20930- allograft, morselized □ 20931- allograft, structural
Laminectomy □ 63081- Corepectomy: Cervical
□ 63001- Laminectomy □ 22585- Arthrodesis anterior interbody technique
□ 63015- 2 or more segments Micro Cervical Discectomy
□ 63045- First level □ 63020- Cervical Discectomy
□ 63048- each additional space □ 69990- operating microscope
□ 69990- operating microscope Other
□ 63042- redo, single space □ Cervical Traction

ADDITIONAL COMMENTS:

Other Special Notes: □ Wheel Chair Bound

□ Nerve Root Monitoring □ Notify Spine Instrumentation Rep- Scott □ Notify Intrathecal Rep- Jennifer