Wiki Spine surgery revision?

[jdibble]

I am confused on the correct way to code this and hoping I can get some help with this. Apparently this patient had a previous laminectomies (in 2-17) on L5-S1. He is being brought back to have a revision surgery done. I am confused on the correct codes to be used for this procedure. He states in the note that he did complete laminectomies and foraminotomies on L5 and S1 were done. So would this be coded as 63042 and 63044 or 63047, 63048 or 63042, 63047? The description of 63042 is confusing as Laminotomy (not laminectomy), reexploration not revision, etc. The revision part vs. complete lamintectomy is confusing me too! The OP note is below:

Procedure Performed
Revision L5 laminectomy 63042
S1 laminectomy 63048
L5-S1 posterolateral fusion 22612
Pedicle screw instrumentation system was globus Medical Creo 22840
Aspiration of the right PSIS for 30 cc of bone marrow aspirate for bone grafting purposes to 20939

Technique/Description of Procedure
On October 6, 2021 patient was brought the operating was placed under general endotracheal anesthesia. When adequate anesthesia was obtained he was placed in a prone position on the Jackson table. His head upper and lower extremities were appropriately position padded. Lumbar spine was prepped and draped usual sterile manner with Betadine prep. Lateral x-ray was obtained with an 18 gauge spinal needle placed for level localization. Based upon the x-ray the surgical field was infiltrated with 60 cc of 1 500,000 dilution epinephrine solution. Based upon the same x-ray direct posterior approach to lumbar spine was. This was done and blunt sharp and electrocautery dissection. It was taken out to the transverse process of L5 bilaterally and the sacral ala bilaterally. After adequate exposure attention was brought to the decompression where in a subperiosteal fashion a combination of Leksell rongeur is Kerrison rongeur is and 3 mm neuro tip bur were utilized to perform complete laminectomy at L5 and S1 intervening ligamentum was excised lateral recesses decompressed and foraminotomies performed. At the completion of the decompression there was no pressure on the L5 or S1 nerve roots bilaterally or centrally. Attention was then brought to the fusion where the pedicles were entered with a bur probed dilated and 6.5 x 45 mm screws were placed in the L5 pedicles bilaterally and 7.5 x 35 mm screws in the S1 pedicles bilaterally AP lateral images were obtained noting appropriate levels of surgery and appropriate placement of the screws. A posterior rod construct was created and final tightened. The right PSIS was entered with 3 hole trocar and 30 cc of bone marrow aspirate were obtained changing directions after each 4 cc of aspiration. This was combined with the locally harvested bone graft from the laminectomies and facetectomies in 5 cc of demineralized bone matrix and this combination was placed in lateral gutters after appropriate irrigation decortication. Medium Hemovac drain was placed deep to the fascia fascia was closed with interrupted 0 Vicryl sutures. Subcutaneous tissue and skin were closed and 3 sequential layers ending in a 3 O on diet subcuticular Monocryl stitch. Steri-Strips Xeroform gauze fluff gauze op site dressing were applied the patient was awake in the operating room extubated brought to recovery room in satisfactory condition.

Thank you in advance for your explanations and all help I can get!

Jodi

 

[nickelclaw]

Hello,
I read this as a laminectomy for decompression of spinal nerve through the lateral recess thus 63047 and 63048 is the way I would go. If there is a dx on OP for stenosis then per the AHA coding clinic Dec 2012 "if laminotomy (laminoforaminotomy) instead of laminectomy was performed but spinal stenosis as dx then per dx indication in CPT description supersedes work performed"

In 3m or CPT book for the 63047 has in description (eg. spinal or lateral recess stenosis) that is what the above is referring to.
Also if a "redo laminectomy w/o recurrent hesitated disc" you would also be in the 63045-63048 range instead of 63040-63044

Look at it this way for 63040-63044 is for a re-exploration or for recurrent herniation. Also use mod 50, LT, RT. Note that these are for interspace.

63045-63048 in description is for unilateral or bilateral so no laterality mods are needed. Note these are per segment (L1-L2 would be two segments)
Hope this isn't confusing. Below I will add two OP notes to reference:

At this point in time, revision decompression was performed on the right. Decompression was then performed removing the inferior aspect of the L2 lamina undercutting L2/3 facet joint. Nerve root retractor was used to retract the right L2 nerve root and an HNP was encountered. A 15 blade entered the disc and disc material removed with a pituitary. This At this point in time a Woodson the traversing nerve roots were free, and there was no dural buckling. A durotomy was ovserved in the right lateral recess, and this was closed as described in a separate operative note by
63042

An incision was made overlying the spinous process of L5 and carried through the skin and subcutaneous tissue. The fascia was incised just to the left of the midline and the muscle was dissected off the spinous process and lamina. The retractor was put in place. A laminotomy defect was created with the Midas Rex and Kerrisons. Medial facetectomy was done. Because of the spondyolysis, the entire inferior facet process was resected. The entire laminar arch of L5 was very mobile. The ligamentum flavum was opened and the opening enlarged with a Kerrison.

Exploration revealed that the nerve was compressed by the ruptured disc underneath it and the lamina/ligamentum flavum over it. Eventually the root/thecal sac were mobilized and gently retracted. Ruptured disc was identified with multiple free fragments over L5. Multiple fragments were obtained. All of these fragments were removed. The nerve was allowed to fall back into its original position and found to be under no tension. The disc space was not entered as there was no clear hole in the annulus.
63047

This reference came from the Coder's desk reference by Optum 360:
63045-63048
The patient is face down. Magnification may be used during the procedure. The physician makes a midline incision overlying the affected vertebrae. Fascia is incised. Paravertebral muscles are retracted. The physician removes the spinous processes with rongeurs. If the stenosis is central, the physician removes the lamina out to the articular facets using a burr. If the compression is in the lateral recess, only half of the lamina is removed. A Penfield elevator peels the ligamentum flavum away from the dura. Nerve root canals are freed by additional resection of the facet, and compression is relieved by removal of any bony or tissue overgrowth around the foramen. Removal of the lamina, facets, and bony tissue or overgrowths may be performed bilaterally when indicated. The rongeur, retractor, and microscope are removed. A free-fat graft may be placed over the nerve root(s) for protection. If the ligamentum flavum was spared, it is placed over the free-fat graft. Paravertebral muscles are repositioned and the deeper tissues and skin are closed with

 

[jdibble]

Thank you so much Nickelclaw!! This is very helpful and just what I needed. A little confusing...lol. But I think I can understand this a little bit more now!!