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Disc decompression with excision

  1. #1
    Default Disc decompression with excision
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    Post Op: Left T11 and T12 herniated nucleus polposus with left radiculitis

    Procedures: Left T11 and T12 intervertebral disc decompression with excision of intervertebral disc with fluoroscopic assistance

    Description: After informed verbal and written consent had been obtained, the patient was placed in the prone position. All pressure points were padded. She was sedated to a level of comfort per Anesthesia. A left paramedian incision was made and carried down bluntly to the T11 and T12 neuroforamina. A small 1.5 mm annulotomy was performed initially to the T11 and T12 levels. A radiofrequency ablator procedure was performed across the previously fine annular tears at the T11 and T12 level extending from just the right of midline over to left posterolateral disc wall. A working channel has been created by dilation and the posterior lateral disc protrusion of the neuroforamen at the T11 and T12 levels were excised sharply.

    The physician's office coded 63077 and 63078, I queried the office because I do not feel this dictation supports these codes. The office states the physician feels these codes are appropriate. I was just wanting some other opinions on how you would code. I think I am just going to code the radiofrequency. Any thoughts are greatly appreciated!!
    Last edited by bethh05; 05-27-2009 at 02:56 PM.

  2. #2
    Albany, New York
    I disagree with 63077 & 63078.
    Based on what is documented, I would go with 63046 & 63048.

    Just are they doing an "anterior approach" when patient is positioned prone?
    Karen Maloney, CPC
    Data Quality Specialist

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