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Neurosurgery Coding Alert

Reader Question:

Removal of Pseudoarthrosis

Published on Sat Jan 01, 2000

Question: Our physician wants us to code for the removal of pseudoarthrosis, redo laminotomy (L4/L5) and removal of pedicle screws. I cannot find a code for the removal of the pseudoarthrosis. Can you help?

Laurie Loftesness, Practice Manager
Antelope Valley Neuroscience
Lancaster, Calif.

Answer: The removal of the old pseudoarthrosis is considered part of the re-exploration, says Susan Callaway-Stradley, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C. If the removal is so complex that it significantly extends the time and effort to perform the procedure, then the surgeon may seek extra reimbursement by submitting the claim with an operative report and adding modifier -22 (unusual procedural services) to the re-exploration code.
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