Dr. has L5-L4 hemilaminectomy, foraminectomy on the right side. I am saying 63030, but he is saying 63047 because of the foraminectomy. This cannot be correct?
CPT guidelines indicate foraminotomy. Would the "ectomy" change anything? What are the key words you advise the physician to differentiate 63030 vs 63047. Also, here is the op on above scenario: Thanks!
DX: Forminal spinal stenosis
PROCEDURE: L5-L4 hemilaminectomy, foraminectomy on the right side.
PROCEDURE IN DETAIL: An incision was made on back at appropriate level. Knife dissection was taken down through the sub tissue where the fascia lie. The fascia on the right side of the spine was stripped. The deep Taylor retractor was placed. An intra-operative x-ray confirmed fluro at the proximal L5 pedicle and then dissected up, and as able to trace out the foramen at L4-L5. There appeared to be some compression at this lamina into the next foramen, there was significant stenosis as well as adherent tissue that was adhered and stuck to the dura. I was able to dissect this down to the S1 pedicle and traced out the root above or below. There was significant more compression at this level, which was removed. Once that was done, I was able to trace all nerve roots out. The wound was then copiously irrigated with pulsatile saline lavage. The deep fascia was closed with 0 Vicryl, sub tissue with 2-0 Vicryl, running Prolene for skin.
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