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Repeat posterolateral fusion lumbar

  1. Default Repeat posterolateral fusion lumbar
    Medical Coding Books
    Pt had a posterolateral fusion 10/08 on L4-5. On 6/24, part of the op note reads "I then completed the posterolateral fusion down to L5 by exploring fusion at L4-5 posterolateral fusion, which was somewhat scant in parts, removing as much soft tissue in the fusion mass as possible, decorticating and then placing bone graft material out over the decorticated tranverse processes of the L4, L3, and L5 including the remaining fusion mass at L4-5. Thus a 360 fusion was performed at L3-4 and the 360 fusion was completed at L4-5 as well, although the pedicle screw construct was not extended down to the L5 level since that level appeared to be reasonably well fused.

    Is this a repeat fusion at L4-5 or am I over-reading this? And if it is a repeat, do I use code 22612-76?
    Ann Marie CPC
    Watertown, CT

  2. Default
    This is difficult to follow. However, I am thinking it is a repeat fusion. I would use code 22612 but I would leave off the modifier since it is out of the global period.

    Mary, CPC

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