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Neurosurgery Coding Alert

You Be the Coder:

Pseudoarthrosis Removal

Published on Sun Jul 01, 2001

Test your coding knowledge.  Determine how you would code this situation before looking at the box below for the answer.
Question: How should I code for removal of pseudoarthrosis, redo laminotomy (L4/L5) and removal of pedicle screws? I cannot find a code for the pseudoarthrosis removal.

Nevada Subscriber
 

Answer: According to Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C., if the re-exploratory laminotomy involved nerve decompression, facetectomy or foraminotomy, use 63042 (laminotomy ... lumbar), which includes the removal of the old pseudoarthrosis in the re-exploration. If the removal is complex, and significantly extends the time and effort to perform the procedure, the surgeon may seek additional reimbursement by appending modifier -22 (unusual procedural services) to the re-exploration code and submitting the claim with an operative report. If the laminotomy is minimal, report the pseudoarthrosis removal with 22830 (exploration of spinal fusion).
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