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Foraminotomy w removal osteophyte

  1. #1
    Greater Pittsburgh
    Default Foraminotomy w removal osteophyte
    Medical Coding Books
    Patient had previous surgery 1 month ago......Rt L5-S1 foraminotomy with removal of osteophyte, right L5-S1 foramen.

    An incision was made throught the previous scar, through skin, subcu tissue to fascia. Soft tissue elevaed off laterally, the hardware was intact. There was no evidence of any significant epidureal hematoma just some mild serous fluid, it was normal for postoperative findings. We then irrigated copiously with antibiotic solution and we felt with a medium nerve hook, the L5 nerve root in the foramen of L5-S1. There was a small bone spur that was in the foramen right next to the pedicle screw. Using a 1mm Kerrison and 5.0 angled curet, removed the bone spur from the medial, ineferior part of the wall of the L5 pedicle near the pars fracture. Once that was relieve, we could use the micronerve hook and there was no neuroloigc compression thoughout the foraman, the nerve root was mobile. Checkd the disk space L4-L5 with a Woodson, there were no known herniation, S1 nerve root was fine as well on the right. This was irrigated, dry pior to closure.

    I was looking at 63042-78RT

    Any help with CPT would be greatly appreciated. Thank you in adavance.
    jdemar, CPC, CMA

  2. Default
    Since your doctor had to go in the same level again, 63042 would work. I don't use -78 very often but that seems to be what the insurance would want!
    Bruce Crandall, CPC
    North Carolina Specialty Hospital
    Durham, NC

  3. #3
    Greater Pittsburgh
    Thanks again for your help!
    jdemar, CPC, CMA

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