Is this the entire documentation? I feel like something has been left out.
Here's what I'm referring to...
1-"dr. dictates patient had a laminectomy on the left"
2-"The laminotomy of the inferior portion of L4 was performed brought laterally and a medial side facetectomy and then, a foraminotomy was performed at L4-L5."
If the surgeon performs the laminotomy on the opposite side of the laminectomy...maybe both codes could apply. Also, I encourage my surgeons to use phrases like "partial" or "complete/total" removal of the lamina so that there's no confusion as to what was actually done. Is there any other documentation you can add?
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