Op note help


Summerville, SC
Best answers
Patient had previous decompressive lumbar laminectomy at L4-5 (with complete emptying of disc space at this level) with fusion, instrumentation and bone grafting in 2014 w/codes 63047/22633/22840/22851/20936/20930 being billed for that procedure with primary dx of stenosis at L4-5 w/radiculopathy and spondylolisthesis. He returns for procedure last month with primary dx of lumbar radiculopathy with bone overgrowth from L4-5 bone grafting into L5-S1. I am hoping someone can take a look at this documentation and tell me what codes they would bill? Dr wants to bill 63030/69990.

"Previous lumbar incision was reopened...dissected free down to level of lateral structures and instrumentation. Exposure of the intervening space between the pedicle screws of L4 and then L5 and S1. Epidural fibrosis dissected free in the midline and carried out to remnants of the facet structures that were lateral. These were removed using a 5mm bur. Process repeated at L5-S1. Microscope used to remove remaining portion of the bone, including bone underneath the nerve roots at both levels. Irrigation...etc"

We explained to the surgeon documentation did not support 63030 so he completed this addendum:

"The patient underwent bilateral complete facetectomy with removal of disk; however, the disk material that had been present in the intervertebral space was previously removed and replaced with bone (here is referencing the complete discectomy at L4-5 in 2014). As a result, the bone was subsequently removed at L4-5 and at L5-S1 using the same technique with similar findings of bone overgrowth as a result of hypertrophic bone with the disk space."

I am getting 63047/63048/69990

Any thoughts would be appreciated.