coding help - extension fusion

gjenkins1224

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please help!!! i have a minimally invasive PLIF L4-5 w/cages, screws & extension fusion L5-S1;PLIF removal of instrumentation L5 & S1 w auto graft; marrowaspirate copious and a exploration of the fusion L5-S1.

My coding 22633, 22830/59, 22855/51, 22851x2, 63056/59, 38220x2,20936
am i missing something or am I over coding?
 

nrichard

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Hope this helps.

I don't see enough here to code for the 63056. Code 38220 hits CCI edits with 22633, and 22851. I would not use 38220. You only have a cage being placed at L4-5 and 22551 this is counted by interspace not vertebral segment so I would only code for that one time. Also I have questions about using 22855 as he is reinstrumenting, you can't bill removal of hardware if he is replacing this at the same level. (Per CPT Expert Addition). Since I don't have the entire op-note I couldn't say for sure on 22855.
 
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