Wiki 63030 or 63047

[BFAITHFUL]

dr. dictates patient had a laminectomy on the left, and scout fluoroscopy was taken with the spinal needle in place. A 600 mg of clindamycin was given IV. A midline lumbar skin incision was made over length of approximately 2cm through the subq tissue through fat. Superficial and deep fascia was subperiostially on the right side. Another fluroscopy was taken and this confirmed the localization at L4-L5. The laminotomy of the inferior portion of L4 was performed brought laterally and a medial side facetectomy and then, a foraminotomy was performed at L4-L5. The ligament flavum was elevated and totally removed. This exposed the dura including the lateral margin in the lateral gutter. The L5 nerve root was then identified, tied and freed. This was a good foraminotomy. The nerve root and dural tube were then gently mobilized medially and the underlying disc was palpated and visualized. The disc was somewhat soft, but had not herniated. The fluid aspiration was carried out slightly rostrally. Extruded disc material was found and then the disc material was gragmented and quite extensive elevating of the shoulder at the nerve root and the lateral dura. Thorough removal was carried out. Exploration was then performed more medailly and more superiorly including across the mideline. The foramen was explored once more and was found to be completely free. Hemostasis was carefully acquire. closure was then carried out in the usual manner--------

patient has Lumbar Radiculopathy - 724.4

doctor says its both 63030 & 63047

I know that cpt 63047 is usually done for stenosis but not all the time, maybe just 63030?

thanks!!

 

[RebeccaWoodward*]

Is this the entire documentation? I feel like something has been left out.

Here's what I'm referring to...

1-"dr. dictates patient had a laminectomy on the left"

2-"The laminotomy of the inferior portion of L4 was performed brought laterally and a medial side facetectomy and then, a foraminotomy was performed at L4-L5."

If the surgeon performs the laminotomy on the opposite side of the laminectomy...maybe both codes could apply. Also, I encourage my surgeons to use phrases like "partial" or "complete/total" removal of the lamina so that there's no confusion as to what was actually done. Is there any other documentation you can add?

 

[BFAITHFUL]

unfortunately there is not! I bill for the ASC side and to be quite honest I really don't have access to all the doctors, just one or two but I'm trying really hard to convince our ASC director to allow me to communicate with these doctors, she feels this would just be too aggravating for them. I KNOW its CRAZY thinking! this is a huge problem for me!