63030?

JenReyn99

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The doc says this is 63047, but I don't see that. So I'm just checking what everyone else thinks. Thanks again for the help. (these spine questions will slow down as I get more acquainted!).

Op report:
...Fluoroscopic C-arm was brought in to confirm starting point. Dissection is carried through the skin, subcutaneous, and fascial layers. At the fascial layer, incision is limited to the left side only. Fluoroscopic C-arm is brought in to confirm the level. The paraspinal musculature is elevated off the posterior bony elements and retracted laterally to the medial edge of the facet joint. The facet joint and capsule are protected at this time. A small portion of the L5 and S1 lamina are removed. The ligamentum is removed. The thecal sac and traversing S1 nerve root are identified. These are very tented and scarred down to the soft tissues anteriorly. This took slow, meticulous dissection and mobilization of the nerve root and thecal sac. The axilla is found to be extremely scarred down. This again took slow, meticulous mobilization. A moderately large disc fragment is removed. This consists mainly of cartilaginous end plate from the disk. Following removal of this fragment, the thecal sac and traversing never root are freely mobile. Antibiotic solution is used to irrigate the disk space and epidural space. Again, neural elements are checked to make sure they are freely mobile. Hemostasis is achieved with minimal blood loss during the entire procedure. Throughout the procedure, copious antibiotic solution is used for irrigation, tissue retractors loosened intermittently to help with tissue perfusion. Solu-Medrol 60mg preservative-free is then used to bathe the neural elements....and then he documents closure,etc.

He says:63047,76000,62311,64722. I was looking more at 63030, 76000, and 62311. I have no idea if I'm on the right track, but this doesn't appear to be a full laminectomy. Thanks for the help!

Jen
 

jmcpolin

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First the 63047 includes decompression, so no on 64722 and where is he doing an injection 62311? This looks more like a discectomy to me 63030, I dont see any mention of stenosis.
 

malissagiles

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If the main intent of the surgery was to decompress the HNP then the appropriate choice is 63030. If the main intent was to decompress the spinal canal and/or nerve roots due to bone pathology causing stenosis and the HNP was incidental then you would code 63047.

64722 is definitely not reportable and neither is 62311, regardless of whether it is documented or not (which it is not).

76000 is also not reportable. In open spine procedures, the fluoroscopy is typically performed to verify the location as part of the procedure. Therefore, intraoperative fluoroscopy during open spine procedures such as a laminectomy, or discectomy, or fusion is considered an integral part of the procedure and is not separately reportable using a CPT code such as 77003 or 76000.
 
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