Surgical CAPD

ACDF C5–C6

OR-4421 · Okafor, Tessa · James Okonkwo, MD

Coding hold

Observability

Sign & file writes logs and an APM waterfall

Completeness 74% · synthetic demo data only, no real PHI

LLM observability

CAPD findings

Documentation gaps

Computer-assisted physician documentation checks before coding.

Confirm single vs additional level

required

Additional level (22552) is a common missed add-on. Imaging shows only C5–C6.

Graft / cage type unspecified

reimbursement

Allograft vs autograft vs PEEK cage changes implant and graft codes.

Retrieve this operative note

Security

Who can open this note

Treating surgeon vs billing.svc bulk read of FHIR Patients and CAPD notes.

Case facts

OR / room: OR 5

Start: 11:00

CPT hint: 22551

MRN: SYN-098331