Question

PREOPERATIVE DIAGNOSIS: Neck injury, closed posterior cord syndrome caused by a fracture due to a motor vehicle accident.

POSTOPERATIVE DIAGNOSIS: Same as preoperative.

PROCEDURE PERFORMED: Placement of halo crown and vest.

ANESTHESIA: Local.

SURGICAL INDICATIONS: This 56-year-old patient was in a motor vehicle accident, hitting a tree. He was the driver and appears to have sustained a cervical spinal cord fracture at C1–4. He could not be placed in a neck collar because he has a short, thick neck and also because he had a tracheostomy tube. The patient would not be stabilized with traction as he has a distraction injury. It was indicated to place him in a halo vest and crown to immobilize his neck.

PROCEDURE: The hair was shaved behind both ears. There was a sterile
prep done along the forehead region and the region behind both ears. The halo crown was then positioned and stabilized with the three positioners anteriorly and two laterally. I then injected Xylocaine behind both ears and along the supraorbital ridge laterally. I then placed the four pins and torqued them to 8 pounds per sq inch. The hexagonal lock nuts were then tightened. The patient tolerated this well without any apparent complications. The halo vest was then connected to the crown. The crown was placed. A large vest was used but this was still too small for the patient, and on the right side the vest had to be tied with string until some permanent straps could be fashioned by orthotics. During the placement of the vest, I maintained the neck in neutral position and at no time was there any rotation or flexion or extension of the neck.

Using the CPT and ICD-10-CM mauals, indicate the modifier and codes that would be reported.