Wiki Neurosurgery Coding Guidance

[adunlap23]

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?

 

[NRaizman]

Would code this 63030, 63035.
Would code this based on the approach, not where the disc is - this was a 2-level hemilam, facetectomy, foraminal approach, from what you're describing, correct? Not transpedicular or far-lateral.

 

[adunlap23]

Would code this 63030, 63035.
Would code this based on the approach, not where the disc is - this was a 2-level hemilam, facetectomy, foraminal approach, from what you're describing, correct? Not transpedicular or far-lateral.

Thank you for your reply. We had a neurosurgeon join our team a little over a month ago. This is new to me, so I feel like it would be more helpful if I just post the operative report rather than try to explain it, just in case I'm misinterpreting something.

Preop and postop diagnosis: lumbar disc herniation with radiculopathy
Procedures performed: Right L4-5 and L3-4 hemilaminectomies, medial facetectomies, foraminotomies, and far lateral microdiskectomies with microsurgical dissection techniques.

Operative note:
The patient was identified in the preoperative area and brought to the operating room where general anesthesia was administered. Prophylactic antibiotics were given. TEDs and sequential compression devices were placed. The patient was positioned prone on a Jackson table. The lumbosacral region was prepped and draped in standard sterile fashion. A time-out was performed.

Using C-arm fluoroscopy, the L4-5 level was identified. A midline incision was made over the spinous processes of L4 and L5. Subperiosteal dissection was performed along the right side. A localization x-ray confirmed the operative level.

A high-speed drill was used to perform a right L4-5 hemilaminectomy, medial facetectomy, and foraminotomy. The operating microscope was utilized. Epidural tissues were carefully dissected away from the thecal sac and nerve root. The far lateral/foraminal L4-5 disc space was identified and incised. Disc material was removed in a piecemeal fashion with pituitary rongeurs and curettes.

The extruded fragment extended cranially into the L4 foramen and toward the L3-4 disc space. The bony resection was extended to include a right L3-4 hemilaminectomy, medial facetectomy, and foraminotomy to allow removal of the migrated fragment. The extruded disc material was removed. The discectomy was continued until there was no further compression of the thecal sac or nerve root.

Both L3-4 and L4-5 disc spaces were irrigated. No additional loose fragments were identified. Foraminal decompression was widened with Kerrison rongeurs. Hemostasis was achieved.

The wound was closed in layers using absorbable sutures for fascia and subcutaneous tissue. Skin adhesive was applied and a sterile dressing placed. All sponge and needle counts were correct. The patient was awakened from anesthesia and transferred to recovery in stable condition.

 

[NRaizman]

Got it. 63030, 63035 would be my pick here. I think the work of two levels is clearly done here, and it is definitely not a far-lateral or transpedicular approach.