lhoot
Guest
Good Morning,
I need some help in finding a CPT code for a lumbosacral microdiscectomy with no mention of laminotomy of any kind. See documentation below. All the resources I'm coming across suggest 63030, but this code mentions a laminotomy.
Thank you,
Laura
A longitudinal incision was then made over the L5-S1 disk space. Using electrocautery, adequate hemostasis was obtained. We dissected down to the lumbosacral fascia. Once we had reached the lumbosacral fascia, we made a longitudinal incision into the fascial layer in line with our skin incision. We then performed a left-sided periosteal dissection to expose both the L5 lamina as well as the S1 lamina. Once this was completed and the lamina of both L5 and S1 was exposed, we then took a localizing x-ray to make sure that we were at the proper disk space. Once we were at the appropriate disk space and this was confirmed, I then used an upgoing curette in order to peel back some of the ligament between the L5 and S1 disk space. Once the false ligament was removed, I was then able to identify the ligamentum flavum. Using a nerve hook, I slowly elevated the ligamentum flavum and Once the ligamentum was removed at this level, I was able to identify the epidural fat as well as the thecal sac. I did use the number 2 Kerrison to continue to dissect out more laterally and removed the ligamentum at that level. I was then able to easily identify the traversing nerve root. I then was able to tell that given her disk herniation the nerve root was actually under quite a bit of tension. I used a number 4 Penfield 4 in order to slowly mobilize the nerve root from lateral to medial and identified the L5-S1 disk space. Once I was able to identify the L5-S1 disk space and mobilize the nerve root medially, I then made a small annulotomy using an 11 blade into the annulus. I then used a Decker as well as an upgoing and straight pituitary rongeurs in order to remove the offending disk herniation. Once I had removed the offending disk herniation, I did place a Penfield into the L5-S1 disk space to confirm that we had removed the disk. We then used a ballpoint as well as a Woodson to undermine the dura at that level to make sure that there was no evidence of any residual bump or disk herniation causing compression at that level. Once we were done with our diskectomy, I made sure that the excursion of the nerve root was significantly improved and there was no evidence of tension on the nerve root.
I need some help in finding a CPT code for a lumbosacral microdiscectomy with no mention of laminotomy of any kind. See documentation below. All the resources I'm coming across suggest 63030, but this code mentions a laminotomy.
Thank you,
Laura
A longitudinal incision was then made over the L5-S1 disk space. Using electrocautery, adequate hemostasis was obtained. We dissected down to the lumbosacral fascia. Once we had reached the lumbosacral fascia, we made a longitudinal incision into the fascial layer in line with our skin incision. We then performed a left-sided periosteal dissection to expose both the L5 lamina as well as the S1 lamina. Once this was completed and the lamina of both L5 and S1 was exposed, we then took a localizing x-ray to make sure that we were at the proper disk space. Once we were at the appropriate disk space and this was confirmed, I then used an upgoing curette in order to peel back some of the ligament between the L5 and S1 disk space. Once the false ligament was removed, I was then able to identify the ligamentum flavum. Using a nerve hook, I slowly elevated the ligamentum flavum and Once the ligamentum was removed at this level, I was able to identify the epidural fat as well as the thecal sac. I did use the number 2 Kerrison to continue to dissect out more laterally and removed the ligamentum at that level. I was then able to easily identify the traversing nerve root. I then was able to tell that given her disk herniation the nerve root was actually under quite a bit of tension. I used a number 4 Penfield 4 in order to slowly mobilize the nerve root from lateral to medial and identified the L5-S1 disk space. Once I was able to identify the L5-S1 disk space and mobilize the nerve root medially, I then made a small annulotomy using an 11 blade into the annulus. I then used a Decker as well as an upgoing and straight pituitary rongeurs in order to remove the offending disk herniation. Once I had removed the offending disk herniation, I did place a Penfield into the L5-S1 disk space to confirm that we had removed the disk. We then used a ballpoint as well as a Woodson to undermine the dura at that level to make sure that there was no evidence of any residual bump or disk herniation causing compression at that level. Once we were done with our diskectomy, I made sure that the excursion of the nerve root was significantly improved and there was no evidence of tension on the nerve root.