Wiki Help with Back Surgery


Charlottesville, VA
Best answers
Please help me with coding this back surgery (I am no good with backs!!).

Pre-operative: Lumbar stenosis, central and foraminal and lateral recess of L4-5, recurrent, and L5-S1.

Post-op Diagnosis: Same as pre-operative with addition of recurrent stenosis at L3-4.

Operative Procedure:
1. Lumbar laminectomy and decompression with central laminectomy.
2. Bilateral foraminotomies.
3. Bilateral partial medial facectomies, right and left at L3-4 recurrent. L4-5 recurrent and L5-S1 as well as central midline decompressions.

Description: Back was prepped and draped in routine sterile fashion and using lateral vision fluoroscopy, spinal needle advanced in the L5-S1interspace. Incision extended distally with dissection through the skin and subcutaneous tissues and fascia divided. We progressed inferiorly to soperiorly to obtain good, clean planes before moving into the scar tissue more proximally. Dissection facilitated around the spinous processes, over the lamina and decompression facilitated at each level which included midline laminectomies, partial medial facetectomies and foraminotomies at each level. Scar tissue was excised as well. The arthritic overgrowth from the fact joints was removed and excellent decompressions obtained at each level ......
Last edited:
Please note that there is now a neurosurgery forum, but from what I can see from the dictation L3-4 and L4-5 are redo's and L5-S1 is new. He says he is doing L3-L4 and the left and right but his dictation is not real clear, he doesnt say bilateral in the body of the OR so I wouldnt bill with a 50 modifier. So, I would bill 63042 59, 63047 and 63044.