I coded spine for about 3 years. The four things I was taught by NASS to pull and code from an op report were: decompression, arthrodesis, instrumentation and graft/harvesting. If the disc space was decompressed for the sole purpose of preparing the interspace for fusion,it cannot be billed as it is included in the fusion. However, if a decompression was medically necessary and documented as such in the report, a decompression procedure (eg: laminectomy) can be billed with the fusion. Be careful with the instrumentaiton and read up on the differences between segmental and non segmental as this can trip you up sometimes. Good luck!
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