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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I get this when I check 22830:

Clinical Responsibility
When the patient is appropriately prepped and anesthetized, the provider makes an incision over the vertebrae which were previously fused and dissects down to the bone. He confirms that the fusion has bonded completely and ensures that the bones and surrounding structures are stabilized. He may adjust or replace spinal instrumentation. The provider then irrigates the area, checks for bleeding, removes any instruments, and closes the incision in layers.

IMO, because he makes a statement of what he did and a statement of what his findings were, that would qualify for the code, assuming all the remaining pieces had been completed.
 
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