Question New to Spinal coding

jdibble

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Good day!!

I am new to spinal coding and these procedures are really confusing me! So far I have come up with the following codes: 63040, 63030, 63035, 22612, 22840. I see possibly in the title 20939, 20936, and/or 20930 but I do not think I see any of this in the procedure description. Also, do these codes require RT or LT modifiers if done unilaterally?

Could someone please help me understand what I am looking at in this OP note and the correct CPT codes that they see? Also if you could explain what it is that you see or didn't see compared to the codes I have picked, that would be so helpful! (Sorry, I know this is a very long OP note).

Preoperative Diagnosis
1)Degenerative lumbar spinal stenosis
2) Post-laminectomy syndrome

Postoperative Diagnosis Same

Procedure Performed
L4-5 revision laminectomy with foraminotomy over the right L5 nerve root
L3-4 hemilaminectomy with foraminotomy over the right L4 nerve root
Right L2-3 hemilaminotomy with foraminotomy over the right L3 nerve root
L4-5 posterolateral arthrodesis
L4-5 non-segmental instrumentation
Right posterior iliac crest bone marrow aspirate
Application of autograft bone, Mozaik bone graft substitute & Accell Connexus EVO3 DBM putty with bone chips (from Integra/SeaSpine) for the L4-5 arthrodesis
Continuous intraoperative SSEP, EMG, and pedicle screw stimulation monitoring

Technique/Description of Procedure
Patient is a 78-year-old man with a previous lumbar decompressive operation who has had recurrence and worsening of symptoms after only a few years. He has low back, right buttock, and right posterolateral and anterior thigh pain to the knee. He does not have classic neurogenic claudication, but he gets sitting pain and pain lying in bed with his spine extended. His pain has become severe and he says it is intolerable at this time. He has tried non operative management, culminating in a spinal cord stimulator trial, which was ineffective. He did not get the permanent implantation of the spinal cord stimulator and has requested surgery instead. His pathology is severe on radiographs and MRI imaging. He has market central lateral stenosis at L4-5. His radiographs show that the L4 spinous processes previously been resected suggesting that he has some degree of midline laminectomy. He did not have much laminectomy upon operating on him on looking at it under direct vision, however, so it may have been that the midline spinous process was taken down in order to facilitate reaching across from the opposite side to do foraminotomies with the prior operation. His symptoms have all recurred and therefore this is considered a post laminectomy syndrome. Patient has somewhat hypertrophic facet joints at L2-3 and L3-4 leading to lateral recess stenosis. The decision was made to be sure to decompress the right L3, L4, and L5 nerve roots with any revision operation. Patient was given discussion of risks, benefits, and also understands risks of bleeding, infection, anesthesia complications, cerebral spinal fluid leakage, need for possible subsequent revision surgery, neurovascular injury, among others. Patient gave informed consent and requested the operation.

Patient taken to the operating room where general endotracheal was established by the anesthetist. He was placed on the MTS table in the prone position. Neck was kept flexed on the operating table to prevent hyperextension on the neck. The elbows and shoulders were at 90°. Foam boats were used to protect the arm and the forearms were rotated to neutral position in order to protect the ulnar nerves. Shoulders were a little tight, so the arm boards were dropped more ventral to take the tension off the shoulders. Bony prominences were protected, and the belly was hanging free between the stimulator posts to prevent engorgement of the lumbar venous plexus.

Midline incision was made extending the old incision slightly distally and slightly proximally. Midline fascial incision was made. The Cobb elevator was used to elevate tissues and paraspinal muscles off the spinous process and laminae out to the lateral aspects of the facet joints. There was no spinous process at L4 due to previous resection with the prior operation. L4 and L5 transverse processes were identified under fluoroscopy and the paraspinal muscles were elevated out to the tips of the transverse processes at those 2 levels. The right L2-3 level was opened out to the facet joint later in the case. Pedicle screws were placed after targeting with AP and lateral fluoroscopic images. Pedicle screw placement was a little challenging on this patient due to his obesity at 108 kg and a fairly muscular side wall. It was necessary to place stab incisions through the paraspinals to place the L5 pedicle screws. The L4 pedicle screws were placed through the main operative wound. After the pedicle screws were in position, using four 6.5 x 45 mm pedicle screws, the monitoring tech did pedicle screw stimulation. It took greater than 20 milliamps to stimulate from each pedicle screw site, so the pedicle screws were found to be in excellent position with no evidence of neurological encroachment.

After placement of the L4 and L5 bilateral pedicle screws, attention was turned to the laminectomy. The soft tissues were carefully elevated using a curette, cautery, and rongeur. We expected a midline laminectomy due to the previous resection of the L4 spinous process, but there was very little laminectomy found. It may have been to the spinous process was resected in order to do foraminotomies from across the table with the old operation. A portion of the L3 spinous process was taken down so that an approach the spinal canal could be done cephalad to where the previous work at been done. Also the spinal canal was were post from the caudal end of the old operation at the inferior edge of the L L4 lamina. Laminectomy was carefully performed past the midline toward the left and all the way over to the pedicles on the right at the L4-5 level. The L5 pedicle was identified with a probe and the nerve root was identified as it exited out the foramen. The L4-5 facet joint was undercut making the lateral recess much more generous for the neural elements and also opening up the introitus to the L5 foramen. After completion of the foraminotomy over L5 and a lateral recess decompression at L4-5, attention was turned to L3-4. A right L3-4 hemilaminectomy was carried out, undercutting the facet joint, identifying the right L4 nerve root, and performing a foraminotomy over the nerve root. There were no durotomy is a no spinal fluid leakage throughout the operation. The decompression was accomplished with 3 and 4 mm Kerrison rongeurs, using cottonoid patties to protect the dura.

Attention was then turned to performing a right L2-3 hemilaminotomy with foraminotomy over the L3 nerve root. This was done without taking down the midline bony elements. A power bur was used to thin the inferior edge of the lamina and then hemilaminotomy was carried out with an 3 mm Kerrison. The L3 nerve root was identified and probe out the foramen and the spinal canal and nerve foramen was wide open at this level.

10 mL of Tisseel fibrin sealant was placed over the laminectomy defect and rubbed all about the inside walls of the wound for postop hemostasis.

Pre curved 45 mm rods were placed over the pedicle screw tulips and tightened into place with the locking caps which were tightened with a torque tightener. Final AP and lateral fluoroscopic images were obtained showing excellent position of the bilateral L4 and L5 pedicle screws and placement of the rods.

1 g of powdered vancomycin was placed in the wound for postop infection prophylaxis.

Figure of 8 1. Vicryl stitches were placed in the lumbodorsal fascia. 1. Vicryl subcutaneous interrupted stitches were used for wound closure. Skin edges were brought together with a zip line skin closure. The stab incisions for placement of the L5 pedicle screws were closed with 1. Vicryl suture with subcutaneous interrupted stitches. Mastisol and Steri-Strips were used on the stab incisions. An Optifoam Ag surgical dressing was placed over the central incision and the stab incisions had Band-Aid dressings placed.

Patient tolerated procedure well and was sent to the PACU for recovery. He was slow to wake up with anesthetic agents as the operation took about 6 hours. Estimated blood loss was 900 mL. A hemoglobin midway through the case was about 14.

AP and lateral lumbar spine images were included in the hospital PACS system for documentation and showed excellent position of the implants. Implants were placed in this case because it was a revision laminectomy that was going to require a generous right-sided decompression, and it was desirable to prevent iatrogenic instability by adding an instrumented fusion. The right L2-3 level was a minimal decompression with no introduced instability, and the L3-4 level still had a largely intact inferior aspect of the L3 lamina, so fusions were not done at L2-3 and L3-4.

The monitoring tech found no problems in the SSEP and EMG monitoring, and the pedicle screw stimulation monitoring also showed no evidence of neurologic encroachment or pedicle breaches.

Implants and Devices Four 6.5mm X 45mm pedicle screws, Two 45 mm pre-curved rods, Four locking caps.
Integra/SeaSpine 15ml Mozaik strip
Integra/SeaSpine Accell Connexus EVO3 demineralized bone matrix putty with bone chips, 5 ml.

Thank you so much for all of the help I can get!! I have a number of these spinal procedures and I just don't understand what needs to be coded and why!

Jodi
 

lexvcarter

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I don't see where the posterolateral arthrodesis and the DBM (bone chip) was used.
Also, the 63040 is for cervical only.
 

jdibble

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I don't see where the posterolateral arthrodesis and the DBM (bone chip) was used.
Also, the 63040 is for cervical only.
Thank you for your response! Can I pick your brain for a bit here? :unsure:

OK...so then 63042 would be correct code instead?
What type of documentation would you need to see for the arthrodesis?
What am I looking at then in the third paragraph of the description that begins with "Midline incision was made..." - what procedure/CPT code does that represent?
What is the difference between 22612, 22630 and 22633 and when would they be used?
If he had documented the graft materials that he stated in the header, what codes would that have represented?
Are there any other codes I am missing?

Sorry for all the questions! I am grateful for all the answers I can get so I can try and wrap my mind around these procedures!! If you know of any good sources that I can get information on spinal coding for dummies, please let me know! lol.

Thanks,
 

lexvcarter

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I broke it down paragraph by paragraph.
  1. "Midline incision was made extending the old incision slightly distally and slightly proximally. Midline fascial incision was made. The Cobb elevator was used to elevate tissues and paraspinal muscles off the spinous process and laminae out to the lateral aspects of the facet joints. There was no spinous process at L4 due to previous resection with the prior operation. L4 and L5 transverse processes were identified under fluoroscopy and the paraspinal muscles were elevated out to the tips of the transverse processes at those 2 levels. The right L2-3 level was opened out to the facet joint later in the case. Pedicle screws were placed after targeting with AP and lateral fluoroscopic images. Pedicle screw placement was a little challenging on this patient due to his obesity at 108 kg and a fairly muscular side wall. It was necessary to place stab incisions through the paraspinals to place the L5 pedicle screws. The L4 pedicle screws were placed through the main operative wound. After the pedicle screws were in position, using four 6.5 x 45 mm pedicle screws, the monitoring tech did pedicle screw stimulation. It took greater than 20 milliamps to stimulate from each pedicle screw site, so the pedicle screws were found to be in excellent position with no evidence of neurological encroachment."
    • Code 22612 for L4-L5.
  2. "After placement of the L4 and L5 bilateral pedicle screws, attention was turned to the laminectomy. The soft tissues were carefully elevated using a curette, cautery, and rongeur. We expected a midline laminectomy due to the previous resection of the L4 spinous process, but there was very little laminectomy found. It may have been to the spinous process was resected in order to do foraminotomies from across the table with the old operation. A portion of the L3 spinous process was taken down so that an approach the spinal canal could be done cephalad to where the previous work at been done. Also the spinal canal was were post from the caudal end of the old operation at the inferior edge of the L L4 lamina. Laminectomy was carefully performed past the midline toward the left and all the way over to the pedicles on the right at the L4-5 level. The L5 pedicle was identified with a probe and the nerve root was identified as it exited out the foramen. The L4-5 facet joint was undercut making the lateral recess much more generous for the neural elements and also opening up the introitus to the L5 foramen. After completion of the foraminotomy over L5 and a lateral recess decompression at L4-5, attention was turned to L3-4. A right L3-4 hemilaminectomy was carried out, undercutting the facet joint, identifying the right L4 nerve root, and performing a foraminotomy over the nerve root. There were no durotomy is a no spinal fluid leakage throughout the operation. The decompression was accomplished with 3 and 4 mm Kerrison rongeurs, using cottonoid patties to protect the dura."
    • Code 63047 for right L4-L5.
    • Code 63035 for right L3-L4.
  3. "Attention was then turned to performing a right L2-3 hemilaminotomy with foraminotomy over the L3 nerve root. This was done without taking down the midline bony elements. A power bur was used to thin the inferior edge of the lamina and then hemilaminotomy was carried out with an 3 mm Kerrison. The L3 nerve root was identified and probe out the foramen and the spinal canal and nerve foramen was wide open at this level. 10 mL of Tisseel fibrin sealant was placed over the laminectomy defect and rubbed all about the inside walls of the wound for postop hemostasis. Pre curved 45 mm rods were placed over the pedicle screw tulips and tightened into place with the locking caps which were tightened with a torque tightener. Final AP and lateral fluoroscopic images were obtained showing excellent position of the bilateral L4 and L5 pedicle screws and placement of the rods."
    • Code 63030 for right L2-L3. (add modifier to indicate a separate and distinct procedure/level)
    • Code 22840 for instrumentation of the pedicle screws, dual rods at only one fixation point.
  4. Lastly, for the graft codes you wouldn't bill for it. The grafting portion of the surgery would have to be formally dictated. IF they were dictated in the note the codes would be 20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only) and 20939 (Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision).


***This is a great source from AAPC. It will answer your questions about documentation for arthrodesis. The difference between codes 22612, 22630 and 22633 & when to use them. If you have anymore questions let me know!
https://www.aapc.com/blog/25658-procedure-coding-made-simple/
 
Last edited:

jdibble

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I broke it down paragraph by paragraph.
  1. "Midline incision was made extending the old incision slightly distally and slightly proximally. Midline fascial incision was made. The Cobb elevator was used to elevate tissues and paraspinal muscles off the spinous process and laminae out to the lateral aspects of the facet joints. There was no spinous process at L4 due to previous resection with the prior operation. L4 and L5 transverse processes were identified under fluoroscopy and the paraspinal muscles were elevated out to the tips of the transverse processes at those 2 levels. The right L2-3 level was opened out to the facet joint later in the case. Pedicle screws were placed after targeting with AP and lateral fluoroscopic images. Pedicle screw placement was a little challenging on this patient due to his obesity at 108 kg and a fairly muscular side wall. It was necessary to place stab incisions through the paraspinals to place the L5 pedicle screws. The L4 pedicle screws were placed through the main operative wound. After the pedicle screws were in position, using four 6.5 x 45 mm pedicle screws, the monitoring tech did pedicle screw stimulation. It took greater than 20 milliamps to stimulate from each pedicle screw site, so the pedicle screws were found to be in excellent position with no evidence of neurological encroachment."
    • Code 22612 for L4-L5.
  2. "After placement of the L4 and L5 bilateral pedicle screws, attention was turned to the laminectomy. The soft tissues were carefully elevated using a curette, cautery, and rongeur. We expected a midline laminectomy due to the previous resection of the L4 spinous process, but there was very little laminectomy found. It may have been to the spinous process was resected in order to do foraminotomies from across the table with the old operation. A portion of the L3 spinous process was taken down so that an approach the spinal canal could be done cephalad to where the previous work at been done. Also the spinal canal was were post from the caudal end of the old operation at the inferior edge of the L L4 lamina. Laminectomy was carefully performed past the midline toward the left and all the way over to the pedicles on the right at the L4-5 level. The L5 pedicle was identified with a probe and the nerve root was identified as it exited out the foramen. The L4-5 facet joint was undercut making the lateral recess much more generous for the neural elements and also opening up the introitus to the L5 foramen. After completion of the foraminotomy over L5 and a lateral recess decompression at L4-5, attention was turned to L3-4. A right L3-4 hemilaminectomy was carried out, undercutting the facet joint, identifying the right L4 nerve root, and performing a foraminotomy over the nerve root. There were no durotomy is a no spinal fluid leakage throughout the operation. The decompression was accomplished with 3 and 4 mm Kerrison rongeurs, using cottonoid patties to protect the dura."
    • Code 63047 for right L4-L5.
    • Code 63035 for right L3-L4.
  3. "Attention was then turned to performing a right L2-3 hemilaminotomy with foraminotomy over the L3 nerve root. This was done without taking down the midline bony elements. A power bur was used to thin the inferior edge of the lamina and then hemilaminotomy was carried out with an 3 mm Kerrison. The L3 nerve root was identified and probe out the foramen and the spinal canal and nerve foramen was wide open at this level. 10 mL of Tisseel fibrin sealant was placed over the laminectomy defect and rubbed all about the inside walls of the wound for postop hemostasis. Pre curved 45 mm rods were placed over the pedicle screw tulips and tightened into place with the locking caps which were tightened with a torque tightener. Final AP and lateral fluoroscopic images were obtained showing excellent position of the bilateral L4 and L5 pedicle screws and placement of the rods."
    • Code 63030 for right L2-L3. (add modifier to indicate a separate and distinct procedure/level)
    • Code 22840 for instrumentation of the pedicle screws, dual rods at only one fixation point.
  4. Lastly, for the graft codes you wouldn't bill for it. The grafting portion of the surgery would have to be formally dictated. IF they were dictated in the note the codes would be 20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only) and 20939 (Bone marrow aspiration for bone grafting, spine surgery only, through separate skin or fascial incision).


***This is a great source from AAPC. It will answer your questions about documentation for arthrodesis. The difference between codes 22612, 22630 and 22633 & when to use them. If you have anymore questions let me know!
https://www.aapc.com/blog/25658-procedure-coding-made-simple/
Thank you so much!!! That is so helpful! I will check out the link too!
 
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