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Spinal HELP!!!

  1. #1
    Default Spinal HELP!!!
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    I'm not that familiar with spinal procedure and would really appreciate some feedback on this procedure.

    Coded: 22633-22; 63012-59; 63012-59; +22840-59; 22634-22,59; 20936-59; 20930-59; 76000-26
    Dx: M99.83; M43.16

    Preoperative Dx: L3-5 foraminal stenosis with spondylolisthesis after previous laminectomy
    Postoperative Dx: Same

    Procedure:
    1. L3-4 minimally invasive transforaminal lumbar interbody fusion with posterior spinal fusion with modifier for increased complexity due to scar tissue
    2. L4-5 minimally invasive transforaminal lumbar interbody fusion with posterior spinal fusion with modifier for increased complexity due to scar tissue
    3. Insertion of posterior spinal instrumentation from L3-4, which is a 2 level instrumentation utilizing NuVasive Reline pedicle screws and rods
    4. Insertion of interbody cages for spinal fusion at L4-L5 and L3-4
    5. Right L3 Gill laminectomy for spinal decompression
    6. Right L4 Gill laminectomy for spinal decompression
    7. Harvest of local bone for spinal lumbar
    8. Use of allograft bone for spinal fusion to include Osteocel and crushed cancellous allograft bone
    9. Intraoperative use of C-arm fluoroscopy

    Procedure: Biplaner C-arm fluoroscopy was then brought in and localized over the L3-5 region. At this point, the pedicles were then marked with a marking pen. Approximately 4cm incisions were made lateral to the pedicles in a Wiltse approach bilateral L3-5 region and dissection was carried down to the lumbar fascia. At this point, Jamshidi needles were used to place percutaneous screws in a standard fashion with needles being placed under C-arm guidance with neuromonitoring. Neuromonitoring did remain stable throughout placement. Screws were placed after guidewires were placed at L3-5 bilaterally. Guidewires were then subsequentially removed. At this point, the retractor was then assembled at the right L3-5 levels and it was attached to the table arm. The medial blade was inserted. Due to scar tissue, the dissection did take more time and added complexity to the case. A small incidental durotomy occurred due the scar and cottonoid was placed. The L-4-5 facet joint was exposed and osteotome was used to remove the inferior articular process of L4 and this bone was harvested for later use. The full Gill laminectomy and decompression was then completed with a bur with a trap as well as the Kerrisons and curettes to remove the remainder of the bone as well as the ligamentum flavum for full Gill laminectomy and full decompression to include th eexiting L4 and transversing L5 nerve roots. Once this was done, attention was then turned to the disc space. The nerve root retractor was placed. Disc space was incised. The disc was then partially removed. The sizing was then performed, which showed that a 10x10x30 mm 4-degree cage would appropriate. The full disc space prep was completed, including removing the cartilaginous endplates. Once this was done, the bone graft was then placed, which was the local bone mixed with the Osteocel allograft bone. This was packed into the disc space as well as into the cage. The cage was then inserted under C-arm guidance until it was fully seated at the L4-5 interspace. Once this was done, Woodson was used to verify that the nerve roots were completely freed which they were. Attention was then turned to the L3-4 level. Rectractor was then placed at th eL3-4 level and attached to the table arm. and the exact same fashion was done before the Gill laminectomy was completed at the L3-4 level exposing the dura and exiting L3 and traversin gL4 nerve roots until everything was fully decompressed. Again there was significant scar present from the previous laminectomy which added complexity to the case. Once decompression was complete, attention was turned to the disc space. Disc was incised. The disc was incised and partial discectomy was performed.

    The sizers were then utilized and was found that a 10x10x30 mm cage would be appropriate with 4-degress of lordosis. The remainder of the disc space was then fully prepped as well removed wiht the carilaginous endplates. The bone graft was then placed into the disc space utilizing the Osteocel allograft bone as well as the local bone, which was harvested. Cage was then inserted in a standard fashion as well at the L3-4 level and under C-arm guidance until it was fully seated. At this point, the epidural hemostasis was achieved with Gel-Foam wit thrombin, neuro patties and bipolar. The retractor was then reassembled from L3-5 and the intervening blade at L4 was removed. At this point the small durotomy was repaired with 5-0 prolene followed by duragen and deuraseal.

    A valsalva was perfomred and showed no residual CSF leak. the posterolateral dissection was then performed exposing the transverse processes of L3, L4 and L5. These areas were then burred. The wound was then irrigated with sterile normal saline with bacitracin. The remained of the bone graft was then placed with the crushed cancelious and remainder of the Osteocel into the posterolateral gutter from L3-5 for posterolateral fusion. The shims were removed from the remainder of the screw heads. The screw heads with tower devices were then placed at L3-5 and the retractor was then removed. At this point, the screwdriver was used to fully seat the screw at L3-5. The rods were then measured and bent with lordosis, were then placed through the tower devices bilaterally and reduction instrumentation was used to reduce the rods as well as the spondylolithesis and the set screws were then placed and subsequently final tightened.

  2. #2
    Location
    Fort Myers, FL
    Posts
    96
    Default
    This is how I would bill this.

    DX:M48.061, M43.16

    22633-22
    22634
    63012-59
    22842
    22853x2
    20930
    20936

    You can only bill modifier 22 on your primary procedure code.
    63012 has no additional level code. The MUE is 1 so you can only bill for 1 level regardless of how many levels treated.
    Your Instrumentation actually is placed at L3-L5.
    There were two Interbody cages placed, those are separately billable.
    You only need modifier 59 on 63012. But keep in mind that is this is a Medicare plan or a plan that specifically follows CMS then this is not be paid as there is still a CMS Edit bundling decompression work at the same level as an Interbody Fusion.

    Hope this helps.
    Sara Boyce, CPC, CPMA, SRS, AAPC Associate
    Neurosurgical Coder

  3. #3
    Default
    Thank you for the help...

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