ammontagano
Guru
Does this op note warrant a 63030?
Decompressive laminectomy and decompressive bilateral foraminotomies were performed by doing subtotal facetectomies at L4-5 and L5-S1 bilaterally removing bone material. There was extensive facet arthrosis and hypertrophy. The bone was carefully cleaned of all soft tissue and morselized and used as bone graft material. Not much in the way of central canal stenosis. There was significant foraminal stenosis of both levels. Foraminotomies were performed by following each of the nerve roots out onto their corresponding neuroforamina on order to ensure complete decompression of that nerve root.
Next, annulotomies were performed on both sides at both levels carefully retracting neural elements to the midline. There was a large disk herniation on the left side at L4-5 which was subligamentous and also had free fragment components. That disk herniation was successfully removed. A large amount of disk material was removed from the epidural and subligamentous space. The remainder of the epidural space was explored and no further free fragments disk were found. The disk spaces were then prepared for interbody spacers.
Doc also performed interbody and posterolateral fusions. Insurance carrier is taking back $$ for 63030 saying that the clinical documentation does not support this code. Any opinions would be appreciated. Thanks
Decompressive laminectomy and decompressive bilateral foraminotomies were performed by doing subtotal facetectomies at L4-5 and L5-S1 bilaterally removing bone material. There was extensive facet arthrosis and hypertrophy. The bone was carefully cleaned of all soft tissue and morselized and used as bone graft material. Not much in the way of central canal stenosis. There was significant foraminal stenosis of both levels. Foraminotomies were performed by following each of the nerve roots out onto their corresponding neuroforamina on order to ensure complete decompression of that nerve root.
Next, annulotomies were performed on both sides at both levels carefully retracting neural elements to the midline. There was a large disk herniation on the left side at L4-5 which was subligamentous and also had free fragment components. That disk herniation was successfully removed. A large amount of disk material was removed from the epidural and subligamentous space. The remainder of the epidural space was explored and no further free fragments disk were found. The disk spaces were then prepared for interbody spacers.
Doc also performed interbody and posterolateral fusions. Insurance carrier is taking back $$ for 63030 saying that the clinical documentation does not support this code. Any opinions would be appreciated. Thanks
