Documentation for Fusion Exploration

mhstrauss

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One of my surgeons did a fusion exploration as part of a TLIF at an adjacent level...previous fusion was L4-5, now extending to L3-4. For the exploration, he only documented "the fusion at L4-L5 was explored and found to be solid". Is this enough for 22830? He also did instrumentation removal and reinsertion--all of that is much more detailed. I'm just questioning the "exploration" part.

TIA!!
 
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