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Neurosurgery Coding Alert

Reader questions:

Code separately for follow-up discectomy

Published on Wed Oct 21, 2009

Question: The surgeon completed anterior exploration with biopsy and diagnosed an anterior cervical abscess with osteomyelitis at C5-C6. Two days later he performed anterior discectomy and decompression of abscess with cadaver bone fusion. What codes apply? Maine Subscriber Answer: If the surgeon biopsied the vertebra for diagnosis of osteomyelitis, code the first procedure with 20251 (Biopsy, vertebral body, open; lumbar or cervical). CPT does not include a code for open biopsy of the intervertebral disc, so report 22899 (Unlisted procedure, spine). The second surgery is a larger, more definitive procedure that includes debridement and decompression  along with arthrodesis. Code the surgery with 63075 (Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace), +22845-51 (Anterior instrumentation; 2 to 3 vertebral segments [List separately in addition to code for primary procedure]; Multiple procedures), and +20931 (Allograft for spine surgery only; structural [List separately in addition to [...]
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