adunlap23
Guru
The surgeon performed right L4–5 and L3–4 hemilaminectomies, medial facetectomies, foraminotomies, and far lateral microdiscectomies using microsurgical dissection techniques.
The patient had a right-sided L4–5 foraminal/far lateral disc protrusion with an extruded fragment extending cranially up to the L3–4 level. The procedure was originally planned only for the L4–5 space, but the operative note indicates that the bony decompression was extended to include a right L3–4 hemilaminectomy, medial facetectomy, and foraminotomy in order to access and remove the cranially migrated extruded fragment originating from the L4–5 disc.
I am planning to report CPT 63056 for the primary far lateral discectomy at L4–5, but I am unsure whether the additional work performed at L3–4 supports reporting a second level code, since the decompression at L3–4 was performed solely to retrieve the migrated fragment from the L4–5 pathology.
Any thoughts or guidance on whether the L3–4 work is separately reportable in this scenario?
The patient had a right-sided L4–5 foraminal/far lateral disc protrusion with an extruded fragment extending cranially up to the L3–4 level. The procedure was originally planned only for the L4–5 space, but the operative note indicates that the bony decompression was extended to include a right L3–4 hemilaminectomy, medial facetectomy, and foraminotomy in order to access and remove the cranially migrated extruded fragment originating from the L4–5 disc.
I am planning to report CPT 63056 for the primary far lateral discectomy at L4–5, but I am unsure whether the additional work performed at L3–4 supports reporting a second level code, since the decompression at L3–4 was performed solely to retrieve the migrated fragment from the L4–5 pathology.
Any thoughts or guidance on whether the L3–4 work is separately reportable in this scenario?