Neurosurgery Coding Alert

Question: How should I code re-exploration of L3/4, L4/5 with revision of L3 through L5 hardware, and L2-L3 decompression? Answer: The scenario is incompletely detailed to provide definitive guidance. If the initial procedures at L34 and L45 were discectomies, the re-exploration would be reported with 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root [s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar) for (L3/4) and 63044 (each additional lumbar interspace [list separately in addition to code for primary procedure]) for (L4/5). However, if the original procedure was a decompression by laminectomy and facetectomy, the re-exploration would be reported with the same 63047 and 63048, perhaps with the -22 modifier to reflect any significant additional work.For the revision, look at 228xx.... Since the scenario did not differentiate segmental or non-segmental instrumentation, whether extension of instrumentation was performed, or whether removal of instrumentation without replacement was [...]