Patient has L4 fracture, my physician did anterior and posterior fusion. The anterior was done first with 22558,22846,22851,63090(L4).
Then the posterior with 22612,22614(x3),22842,22524,22525(x3),72291.
For the fracture at L4, the physician also wants to add CPT 22325 (L4).
Posterior part of surgery:
Pedicle screw entry points were identified bilaterally at L2,L3,L5, and S1. At each of these locations the pedicle was breached with the Midas Rex high-speed drill and then sounded out using a blunt pedicle finder. The bone was found to be fairly osteoporotic based on the feel with the pedicle finder. All 8 pedicle screw holes were sounded out and verified with a ball-tip, and tapped with a 5.5 mm tap. Then attention was turned to placement of pedicle screws. Because of the patient?s presumed poor bone quality, I was very concerned about potential screw pullout and wanted to enhance the screw purchase with vertebroplasty and methylmethacrylate glue argumentation. Therefore, Kyphone bone cement and bone delivery devices were opened and bone cement prepared according to manufacturers instruction and loaded into syringes. The cement was injected deep into each pedicle screw hole followed by placement of 6.5x45 mm NuVasive Armada pedicle screw bilaterally at S1. Floroscopy showed hardware in good position, and then attention was turned to instrumentation.
The NuVasive Bendine system was used to bend the 5.5 mm titanium rod to fit the tulip heads bilaterally, and these rods implanted and held down temporarily with cap nuts to provide the spine some stability as the laminectomies were performed.
Attention was then turned to decompression. A complete laminectomy of L3 and L4 was then undertaken using Leksell and Kerrison rougers, angled curettes, and the Midas Rex high-sped drill with the M8 cutting bur. Gradually the dural sac was exposed. Ligamentum flavum and overgrown facet complex resected and the dural sac decompressed. When the dura sac appeared to be well decompressed through this whole region, attention was turned to arthrodesis. The Midas Rex high-speed drill was used to decorticate the transverse processes and facet complexes at L2,L3,L4,L5, and the sacrum in preparation for arthrodesis. The wound was irrigated copiously with antibiotic containing saline. The lock nuts were then loosened on the rods and then brought to final tightness with the torque wrench while placing the L4 cage construct under compression. Once the compression had been locked in, all the cap nuts were brought to final tightness with the torque wrench. Remaining Osteocel, the patient?s morselized autograft, and cortial cancellous crushed allograft were then packed on the decorticated bone edges for arthrodesis purposes. The wound was then closed in layers,
1. Can he claim for CPT 63090 (anterior) and CPT 22325 (posterior) for same level at L4?
2. I am not sure what is necessary documentation for CPT 22325. Does the above documentation support CPT 22325?
3. I read somewhere that 22524 cannot be billed for injecting methylmethacrylate glue into pedicle screw hole to stabilize screws.
