tyoung9886
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63042 vs 63047 or both ??? please help !
Reoperation to previously operated lumber spine L4-5. Physician coded as 63042 63044, 63044. He believes he can charge this because he is only going thru same incision. Can anyone please help ?
Here is op report:
POSTOPERATIVE DIAGNOSES:
1. Spinal stenosis, L2-3, L3-4, L5-s1 with bilateral radiculopathy, right greater than left unresponsive to nonoperative measures.
2. lower extremity weakness and motor deficits.
3. Spinal lipomatosis at L2-3
4. Herniated nucleus pulposus L3-4 contributing to his spinal stenosis
5. Previously operated lumbar spine at L4-5 by a midline open type of the procedure.
PROCEDURES PERFORMED:
1. Minimally invasiive lumbar decompression at L2-3, L3-4, and L5-S1 via a right sided approach and extended across midline to decompress both the right and left sides including the exiting and traversing nerve roots at each level
2. Diskectomy L2,L3 and L4 right
3. Reoperation to previously operated lumbar spine.
PROCEDURE:
The first portion of the procedure involved decompressing L2-3 and L3-4 by the placement of a tubular retractor and then taking the decompression across the midline. A laminectomy at L3-4 and L2-3 was done. The partial medial facetectomy was done. A large portion of the right L3-4 facet came out in 1 piece because of the severe degeneration. The lamina were removed completely on the right side . The decompression was carried across the midline, undercutting the spinous process and removing portions of it so that the tube could be pushed over to the patients left side where a laminectomy was done. The partial medial facetectomy was done and the exiting and traversing nerve roots at each level on both sides were decompressed and evaluated. The large amount of fat at L2-3 from spinal lipomatosis was removed from.
The right L4 nerve root was carefully retracted and the disk herniation at L3-4 was identified and removed. The right L4 nerve root was completely decompressed at this point. A Valsalva maneuver indicated no evidence of spinal fluid or dural tear. Copious antibiotic irrigation was done. Meticulous hemostasis was obtained. Then a gelfoam patty was placed across the laminectomy defect. The tubular retractor was then removed and new incision was made just to the right of midline at L5-S1 . The tubular retractor was placed and the lamnectomy was done on the right side and spinous process was partially removed and this allowed visualization of the lamina on the other side , on the patients left side. A laminectomy was done on that side as well as partial medial facetectomy and bothe the traversing and exiting nerve roots were identified and protected. The decompression was assured .
Reoperation to previously operated lumber spine L4-5. Physician coded as 63042 63044, 63044. He believes he can charge this because he is only going thru same incision. Can anyone please help ?
Here is op report:
POSTOPERATIVE DIAGNOSES:
1. Spinal stenosis, L2-3, L3-4, L5-s1 with bilateral radiculopathy, right greater than left unresponsive to nonoperative measures.
2. lower extremity weakness and motor deficits.
3. Spinal lipomatosis at L2-3
4. Herniated nucleus pulposus L3-4 contributing to his spinal stenosis
5. Previously operated lumbar spine at L4-5 by a midline open type of the procedure.
PROCEDURES PERFORMED:
1. Minimally invasiive lumbar decompression at L2-3, L3-4, and L5-S1 via a right sided approach and extended across midline to decompress both the right and left sides including the exiting and traversing nerve roots at each level
2. Diskectomy L2,L3 and L4 right
3. Reoperation to previously operated lumbar spine.
PROCEDURE:
The first portion of the procedure involved decompressing L2-3 and L3-4 by the placement of a tubular retractor and then taking the decompression across the midline. A laminectomy at L3-4 and L2-3 was done. The partial medial facetectomy was done. A large portion of the right L3-4 facet came out in 1 piece because of the severe degeneration. The lamina were removed completely on the right side . The decompression was carried across the midline, undercutting the spinous process and removing portions of it so that the tube could be pushed over to the patients left side where a laminectomy was done. The partial medial facetectomy was done and the exiting and traversing nerve roots at each level on both sides were decompressed and evaluated. The large amount of fat at L2-3 from spinal lipomatosis was removed from.
The right L4 nerve root was carefully retracted and the disk herniation at L3-4 was identified and removed. The right L4 nerve root was completely decompressed at this point. A Valsalva maneuver indicated no evidence of spinal fluid or dural tear. Copious antibiotic irrigation was done. Meticulous hemostasis was obtained. Then a gelfoam patty was placed across the laminectomy defect. The tubular retractor was then removed and new incision was made just to the right of midline at L5-S1 . The tubular retractor was placed and the lamnectomy was done on the right side and spinous process was partially removed and this allowed visualization of the lamina on the other side , on the patients left side. A laminectomy was done on that side as well as partial medial facetectomy and bothe the traversing and exiting nerve roots were identified and protected. The decompression was assured .
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