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Code 22630 with TLIF

  1. #1
    Default Code 22630 with TLIF
    Medical Coding Books
    I billed a 22630 with 63047 & 63048 which is bundled. The carrier paid as bundled and the surgeon wants me to appeal because she did a TLIF and states that on the op notes she listed "further decompression was warranted and necessary" I don't find those exact words in her documentation however, looking at the description of a TLIF, would this warrant further decompression and justify an appeal?

    TLIF description:

    A transforaminal lumbar interbody fusion (called a TLIF) is essentially like an extended PLIF. It was developed in response to some of the technical problems with a PLIF procedure. The main difference between the two spine fusion procedures is that the TLIF approach to the disc space is expanded by removing one entire facet joint (whereas a PLIF is usually done on both sides by only taking a portion of each of the paired facet joints).

    Transforaminal lumbar interbody fusion description

    By removing the entire facet joint, visualization into the disc space is improved and more disc material can be removed. It should also provide for less nerve retraction. Because one entire facet is removed it is only done on one side. Removing the facet joints on both sides of the spine would result in too much instability.

  2. #2
    East Stroudsburg, PA
    Code 63047 is bundled with 22630 per NCCI edits however, it can be reported in addition to the fusion code if performed for decompression (apply the modifier 59 to the decompression) This needs to be CLEARLY stated in the OP report.
    ~Rebecca, CPC, COSC, CPC-I

    "To the world you may be one person, but to one person you may be the world" ~Anonymous

  3. #3
    North Carolina
    I agree...

    If the surgeon is removing disk and/or bony endplate solely with the need to prepare the vertebrae for fusion, then no additional 63000 series code(s) is reported. 63047/63048 can be reported, when in addition to removing the disk and preparing the vertebral endplate, the surgeon removes posterior osteophytes and decompresses the spinal cord or nerve root(s). This requires work in excess of that normally performed when doing 22630. As Becka95 stated, documentation is key....

    I found an article written by the AAOS which speaks of the CPT Assistant article I referenced....
    Last edited by RebeccaWoodward*; 09-21-2009 at 11:03 AM.

  4. Default Rebecca

    Your Link does not work, is there a way of copying and pasteing this article?
    I can give you an email address. I am thinking AAOS put it in the member only section and now I can't get to it.
    thanks if you can help. I'd like that whole article if possible.

    Susan RN CPC

  5. #5
    North Carolina

    Sent you a PM.

  6. Default
    Rebecca I see you are versed on the neurosurgery coding and we have an op-note we've coded 3 different ways will you please help.

    PREOPERATIVE DIAGNOSIS: Adjacent level disease at L3-4 with severe stenosis.
    POSTOPERATIVE DIAGNOSIS: Adjacent level disease at L3-4 with severe
    1. We did L3 laminectomy, L3-4 decompression and resection of synovial cyst.
    2. Bilateral facetectomies and foraminotomies.
    3. Also decompression of the thecal sac.
    4. Posterior diskectomy at L3-4.
    5. Placement of posterior interbody arthrodesis at L3-4.
    6. Placement of biomechanical device 12-mm lordotic PEEK cage packed with
    autograft bone calcium phosphate posterior instrumentation from L3 through
    7. Removal of old drives at L4-5.
    8. Exploration of fusion at L4-5.
    9. Re-insertion of rods from L3 to L5.
    10. Posterolateral arthrodesis at L3-4.
    11. Use of fluoroscopy.
    ANESTHESIA: General.
    DRAINS: Placement of JP drain.
    INDICATIONS FOR SURGERY: Mr.----- is a pleasant 68-year-old male who is
    well known to me and is status post L4-5 TLIF several months ago. However,
    the patient started developing adjacent-level disease with severe stenosis
    and synovial cyst formation. The surgery was offered to him to him to entail
    the above procedures. The surgery was discussed with him. Risks included
    infection, bleeding, CSF leak, need for additional surgery. Despite that,
    the patient agreed to surgery and wished to proceed.

    PROCEDURE: The patient was brought to the operating room. After general
    anesthesia was induced, he was placed on the operating table in the prone
    position. All body contacts with the table were appropriately padded. He
    was then prepped and draped in a surgical standard fashion. A time-out was
    taken. Then a midline incision was performed over the old incision. The
    muscles and fascia were taken out to expose the posterolateral elements. An
    x-ray was taken to confirm our level. Then a laminectomy at L3-4 was
    performed. We encountered large facets, large hypertrophied ligamentum
    flavum. These were all removed to decompress the thecal sac.
    Once this was done, then we placed pedicle screws at L3-4 bilaterally. We
    used 6.5 x 50s. Then, we removed the old drives from L4-5. Then we did a
    diskectomy at L3-4, decorticated the interbody endplates preparing for
    fusion. Then a 12-cm lordotic PEEK cage was placed under fluoroscopic
    guidance after it was packed with autograft bone calcium phosphate. Once
    this was done, copious irrigation was performed and hemostasis was obtained.
    Then we brought in the rods that were cut to size and bent to shape, placing
    the screw heads from L3 to L5 and anchored with setscrews. Once this was
    done, then the posterolateral elements at L3-4 were decorticated and prepared
    for fusion. Then, we placed autograft bone calcium phosphate for
    posterolateral elements for fusion. A 7-flat JP drain was placed and 2 g of
    vancomycin powder was inserted in the surgical bed to reduce surgical
    infection. Once this was done, the muscles and fascia were closed using
    0-Vicryl interrupted suture, subcutaneous fascia with 2-0 Vicryl suture, and
    skin with staples.

    1st coding: 22633,63047-59,22842,22851,63048-59
    2nd coding: 22630,22851,22842
    3rd coding: 22633,63030-59,22842,22851,63035-59

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