Provider performed L5-S1 Lami and a fusion and I noticed there is a bundling issue and unable to locate the NCCI edit. please assist. Thank you
My code selection-
22633- M47.36/M48.061
63012/59-M43.17/M96.1 (bundled due to being in the same interspace) am I correct using the 59 modifier
22840-M48.061
22853-M43.17
OPERATIVE PROCEDURE:
1. L5-S1 posterior and interbody fusion.
2. L5-S1 Gill procedure with foraminotomies.
3. L5-S1 pedicle screw instrumentation with RTI screws.
4. Insertion of interbody fusion cage, L5-S1 on the right.
5. Bone grafting with morselized local bone, Infuse, and Trinity Elite
bone graft.
INDICATIONS: This patient with progressive, intractable right leg
pain and was found to have severe foraminal stenosis on the right at L5-S1
and some at L4-L5, but the L4-L5 level was spontaneously fused. Failing
conservative measures, he elected to proceed with L5-S1 posterior and
interbody fusion.
PROCEDURE: The patient was taken to the operating room where, after
satisfactory induction of general endotracheal anesthesia, a Foley catheter
and pneumatic hose were placed. The patient was turned prone on a Jackson
frame. The back was prepped and draped with DuraPrep and Ioban
Steri-Drape. Previous incision from L4-L5 laminectomy was reopened and
extended down through skin, subcutaneous tissue, and fascia onto the Gill
fragment at L5-S1 and over the prior right-sided laminotomy at L4-L5. I
then extended the dissection out onto the transverse processes of L5 and S1
bilaterally. These were decorticated. After irrigating the wound, Infuse
and morselized local bone from the laminectomy, which will be described
below, were packed into the lateral gutters bilaterally.
The Gill procedure was performed by carefully dissecting the facet
ligaments. I removed the spinous process, and I removed the midline
portion of the lamina and then was able to carefully grasp the individual
halves of the lamina with a rongeur. I divided remaining ligamentous
attachments and lifted these away from the dura and the foramen. Wide
foraminotomies were then performed, removing hypertrophic tissues from the
foramina bilaterally. The right was substantially tighter than the left.
With an intervertebral spreader between the tiny S1 process and the L4
process, which was fused to L5, I was able to distract the space and then
introduce some paddles into the right side of the disk space and gently
expand it from no space up to 9 mm. A 9 mm scraper was used to remove the
cartilage endplates from the vertebral bodies, and then after trialing with
a 9 mm spacer, a 9 x 27 mm cage was filled with Trinity Elite bone graft
and tapped into place.
An O-arm spin was carried out. Under Stealth guidance through two separate
small paramedian Wiltse incisions, screws were passed into the L4 and L5
using 45 mm, 6.5 mm diameter screws. These were confirmed in good
position. Then rods were passed through the screws and set screws
tightened to appropriate torque with gentle compression on the right side
over the cage. The bone graft had been previously placed onto the
decorticated transverse processes as described above. The wounds were
irrigated again with IrriSept and closed over a Hemovac drain and
vancomycin powder, using 0 Vicryl sutures in the fascia, 2-0 Vicryl used in
the subcutaneous tissue, and 3-0 Monocryl in the skin. The wounds were
infiltrated with a mixture of Marcaine with epinephrine, Depo-Medrol, and
Toradol. Dry, sterile dressings were placed and drain secured, and the patient was taken to recovery room in satisfactory condition.
The Assistant was present for the entire procedure and was instrumental in the safe
performance of the procedure by assisting with positioning, exposure,
suctioning during the decompression, assisting with instrumentation, and
closure.
My code selection-
22633- M47.36/M48.061
63012/59-M43.17/M96.1 (bundled due to being in the same interspace) am I correct using the 59 modifier
22840-M48.061
22853-M43.17
OPERATIVE PROCEDURE:
1. L5-S1 posterior and interbody fusion.
2. L5-S1 Gill procedure with foraminotomies.
3. L5-S1 pedicle screw instrumentation with RTI screws.
4. Insertion of interbody fusion cage, L5-S1 on the right.
5. Bone grafting with morselized local bone, Infuse, and Trinity Elite
bone graft.
INDICATIONS: This patient with progressive, intractable right leg
pain and was found to have severe foraminal stenosis on the right at L5-S1
and some at L4-L5, but the L4-L5 level was spontaneously fused. Failing
conservative measures, he elected to proceed with L5-S1 posterior and
interbody fusion.
PROCEDURE: The patient was taken to the operating room where, after
satisfactory induction of general endotracheal anesthesia, a Foley catheter
and pneumatic hose were placed. The patient was turned prone on a Jackson
frame. The back was prepped and draped with DuraPrep and Ioban
Steri-Drape. Previous incision from L4-L5 laminectomy was reopened and
extended down through skin, subcutaneous tissue, and fascia onto the Gill
fragment at L5-S1 and over the prior right-sided laminotomy at L4-L5. I
then extended the dissection out onto the transverse processes of L5 and S1
bilaterally. These were decorticated. After irrigating the wound, Infuse
and morselized local bone from the laminectomy, which will be described
below, were packed into the lateral gutters bilaterally.
The Gill procedure was performed by carefully dissecting the facet
ligaments. I removed the spinous process, and I removed the midline
portion of the lamina and then was able to carefully grasp the individual
halves of the lamina with a rongeur. I divided remaining ligamentous
attachments and lifted these away from the dura and the foramen. Wide
foraminotomies were then performed, removing hypertrophic tissues from the
foramina bilaterally. The right was substantially tighter than the left.
With an intervertebral spreader between the tiny S1 process and the L4
process, which was fused to L5, I was able to distract the space and then
introduce some paddles into the right side of the disk space and gently
expand it from no space up to 9 mm. A 9 mm scraper was used to remove the
cartilage endplates from the vertebral bodies, and then after trialing with
a 9 mm spacer, a 9 x 27 mm cage was filled with Trinity Elite bone graft
and tapped into place.
An O-arm spin was carried out. Under Stealth guidance through two separate
small paramedian Wiltse incisions, screws were passed into the L4 and L5
using 45 mm, 6.5 mm diameter screws. These were confirmed in good
position. Then rods were passed through the screws and set screws
tightened to appropriate torque with gentle compression on the right side
over the cage. The bone graft had been previously placed onto the
decorticated transverse processes as described above. The wounds were
irrigated again with IrriSept and closed over a Hemovac drain and
vancomycin powder, using 0 Vicryl sutures in the fascia, 2-0 Vicryl used in
the subcutaneous tissue, and 3-0 Monocryl in the skin. The wounds were
infiltrated with a mixture of Marcaine with epinephrine, Depo-Medrol, and
Toradol. Dry, sterile dressings were placed and drain secured, and the patient was taken to recovery room in satisfactory condition.
The Assistant was present for the entire procedure and was instrumental in the safe
performance of the procedure by assisting with positioning, exposure,
suctioning during the decompression, assisting with instrumentation, and
closure.