Wiki Help, 63020 or 63045?

erinreid1234

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Any help would be appreciated for the Spine Surgery below. I personally think/usually code and have seen mostly that when a patient is diagnosed with Spinal Stenosis that we code the 63045, 63046, or 63047 CPT codes and NOT the 63020 or 63030 CPT codes. I really need advice on what y'all think. Thank you.


DIAGNOSES:
1. Left C8 radiculopathy.
2. Left C7-T1 foraminal stenosis.

OPERATION PERFORMED: Left C7-T1 keyhole foraminotomy.

ANESTHESIA: General endotracheal.

INTRAVENOUS FLUIDS: 1 liter lactated Ringer's.

ESTIMATED BLOOD LOSS: 10 mL.

DESCRIPTION OF PROCEDURE: After successful general endotracheal anesthesia and
administration of IV antibiotics by the anesthesia staff, the patient was placed
prone on the Jackson table with arms tucked and the shoulders taped under
gentle traction. Care was taken to pad all bony prominences. The head was on a
Shea headrest. The neck was then prepped and draped in the normal sterile
orthopedic fashion.

The procedure was then initiated by making a midline skin incision over the C7
and T1 spinous processes as visualized on fluoroscopy and palpated by bony
landmarks. Dissection was carried down through subcutaneous tissue to the
underlying fascia and ligamentum nuchae. This was incised in the midline and
then subperiosteal dissection was carried out over the lamina of C7 and T1 to
expose the interspace. Care was taken to preserve the facet capsule at this
point. We then placed a towel clip in the supraspinous ligament of C7, and we
also placed a spinal needle higher up, so that we could count down from C2 to be
sure that we were at the C7 spinous process. We were satisfied with the
imaging. At this point, the microscope was brought in for the decompressive
portion of the procedure. The high-speed bur was used to perform a moderate
size laminotomy at C7. We took a little bit of the superior aspect of T1, and
first thing we did was we localized the pedicle at T1 to be sure that we had
defined the lateral border of the canal. We then removed the ligamentum flavum
and undercut the lamina to work our way out to the pedicle of C7. At this
point, we could slide a back-angled curette out the neural foramen with the
exiting C8 nerve root, although we could not visualize the nerve root at this
point. Satisfied with our landmarks, we used the high-speed bur to remove
approximately 50% of the facet. We then undercut this and basically dissected
and followed out that C8 nerve root. We then undercut even further out
laterally. At this point, again we had basically skeletonized the nerve root
from the C7 pedicle all the way down to the T1 pedicle. We could palpate out
the neural foramen with a nerve hook confirming that the C8 nerve root was
decompressed throughout its entire course. At this point, we were satisfied
with the decompression. There was a fair amount of facet osteophyte and
thickened capsule, and there was clearly some compression from the ventral side
which felt like disk osteophyte complex and therefore not disk material that
could be removed via diskectomy. Again, the nerve was well decompressed, and we
were satisfied at this point. The wound was copiously irrigated with normal
saline. FloSeal was used to obtain final hemostasis within the epidural space.
We did have some mild residual oozing, and we decided to place a medium Hemovac
drain deep to the fascia. We then closed the wound in layers using 0 Vicryl in
an interrupted figure-of-eight fashion in the fascia to form a watertight
closure. Subcutaneous layer was closed using 2-0 Vicryl in an interrupted
buried fashion followed by 3-0 Monocryl in a subcuticular running fashion
followed by Dermabond. We did infiltrate the wound with 0.5% Marcaine with
epinephrine for postoperative analgesia. Again, skin final closure was
Dermabond after the Monocryl. A Telfa/Tegaderm bandage was applied.
 
I would code to the stenosis codes because they did not perform a discectomy and you need to perform a discectomy in order to use 63020. From what I can tell, they realized it was an osteophyte causing the compression, not a disc.
 
I would code to the stenosis codes because they did not perform a discectomy and you need to perform a discectomy in order to use 63020. From what I can tell, they realized it was an osteophyte causing the compression, not a disc.
You are awesome!!! Thank you so much for your help! Let me know if I can help you in the future!!
 
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