Wiki Please help

[khaleef]

Please help with correct coding of this note. Are codes 63266 and 63055 correct?

POSTOPERATIVE DIAGNOSIS:
epidural lesion-disc herniation
*
PROCEDURE PERFORMED:
transpedicular far lateral discectomy. Resection of intraspinal extradural lesion
microdissection techniques
*
*
An incision was made with a #10 blade over the thoracic and exposure was carried out with Cobb periosteal and monopolar cauterization. Confirmatory x-ray was performed. The attending radiologist was called and on speakerphone confirmed that the marker was at the location of the lesion on MRI. Medial wall of the pedicle was drill down and laminectomy, medial facetectomy, and foraminotomies were performed with the Midas Rex drill with AM8 drill bit, Leksell rongeur, Woodson tip elevator, 4-0 Kerrison, 3-0 Kerrison, 2-0 Kerrison, and 1-0 Kerrison rongeur at levels T12, L1. Extension of laminectomy and foraminotomy and removal of lateral recess ligament and compression was performed with 1-0, 2-0, and 3-0 Kerrison rongeurs. Extensive lesion, consistent with disc fragment, was removed. Additionally, curettes were used to elevate the ligament off the neural elements. Woodson tip elevator was used to demonstrate decompression of the neural elements. Copious irrigation was performed. Hemostasis was achieved. Fascia was closed with 1-0 Vicryl sutures, dermis closed with 2-0 Vicryl sutures, and skin closed with staples.

 

[meghanhannus]

Hello khaleef,

I agree with CPT 63055 (thoracic) for T12 and have CPT 63056 (lumbar) for L1 & CPT 69990 for micro-dissection technique(I don't know if that's payable). I am thinking that since these codes include the disc removal and the lesion was on the disc or a disc fragment removed maybe the lesion should not be coded separately??


CPT 63055/63056:[/U] This procedure is performed to relieve pressure on the spinal cord, equina, and nerve roots caused by a herniated disc. The physician approaches the herniated disc through the pedicle on the side of the disc's bulge. Additional exposure is made by removing the lamina and facet joint. The physician removes the disc fragments and closes the wound in layers.

What I see in the documentation that you have provided: "Extensive lesion, consistent with disc fragment, was removed"

Hope this somewhat helps~

M.Hannus, CPC, CPMA, CRC