Neurosurgery Question


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Codiing Scenario....
Our patient has lumbar stenosis at L5-S1 level that has previously been fused. Our physician did a take down of lumbar fusion at the L5-S1 with facetectomy at L5-S1 and foraminotomies over the L5 and S1 nerve roots. Would you code this as 63047/63048 with modifier 52 or would you code this as 64999? He did not do a laminectomy.

Thanks in advance.
Without seeing the dictation, 63042/63044 seems to fit better since it appears it's a reexploration. I consulted with my neurosurgeon and he also concurs. If it was bilateral, be sure to add modifier 50.

I also asked one of my neurocoder guru's and here's her thoughts:

"Start out with the fusion exploration 22830. He probably does not note the laminectomy because the lamina was previously removed (just guessing here). I believe that this would still qualify for a reexploration 63042, unless he did COMPLETE foraminotomies and facetectomies. See if this describes what the doc did. Had the lamina been there, it would have been included in order to access the foramina"

Again, without seeing the op-note it's rather hard to tell...but 63042 is in agreement with my resources.