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laminectomy 63005?

  1. Default laminectomy 63005?
    Medical Coding Books
    The doctor wants to bill CPT 63030 or 63047 but I'm not
    sure if instead it should be 63005? because he clearly states that he did a bilateral laminectomy but does not state a foraminotomy or a facetectomy was performed.
    Please see op note below. Thank you.


    DX: Spinal stenosis and right lumbar radiculopathy at L4-L5

    OP NOTE:

    After induction of general endotracheal anesthesia, the patient was placed into the prone posture on the Kambin frame. He was protected in appropriate areas. He did receive 1g of Ancef prior to the procedure. The level was determined with a needle and checked with
    x-ray control. I then approached the spine with the midline incision.
    It was carred down into the subcutaneous tissue. The fascia was opened. A subperiosteal dissection was carried out on both sides of the spinous process down to the lamina. Soft tissue was stripped on each side. Primary symptoms were to the right. Therefore, mjaority of dissection was on that side. However, I did remove the spinous
    process for the laminectomy. The lamina was opened bilaterally.
    Further dissection was carried out towards the right neuroforamen. I elected to keep the ligamentum flavum intact. The bony decompression had been carred out. I then opened a neuroforamen and I checked this
    with a woodson. There was ample space. The wound was irrigated.
    Closure was then with 2-0 Vicryl in the deep fascia. The subq tissue was closed with 3-0 undyed Vicryl

  2. Default
    Any spine coders out there??

  3. #3
    Location
    North Carolina
    Posts
    3,126
    Default
    Quote Originally Posted by BFAITHFUL View Post
    The doctor wants to bill CPT 63030 or 63047 but I'm not
    sure if instead it should be 63005? because he clearly states that he did a bilateral laminectomy but does not state a foraminotomy or a facetectomy was performed.
    Please see op note below. Thank you.


    DX: Spinal stenosis and right lumbar radiculopathy at L4-L5

    OP NOTE:

    After induction of general endotracheal anesthesia, the patient was placed into the prone posture on the Kambin frame. He was protected in appropriate areas. He did receive 1g of Ancef prior to the procedure. The level was determined with a needle and checked with
    x-ray control. I then approached the spine with the midline incision.
    It was carred down into the subcutaneous tissue. The fascia was opened. A subperiosteal dissection was carried out on both sides of the spinous process down to the lamina. Soft tissue was stripped on each side. Primary symptoms were to the right. Therefore, mjaority of dissection was on that side. However, I did remove the spinous
    process for the laminectomy. The lamina was opened bilaterally.
    Further dissection was carried out towards the right neuroforamen. I elected to keep the ligamentum flavum intact. The bony decompression had been carred out. I then opened a neuroforamen and I checked this
    with a woodson. There was ample space. The wound was irrigated.
    Closure was then with 2-0 Vicryl in the deep fascia. The subq tissue was closed with 3-0 undyed Vicryl
    Since I'm not familiar with your surgeons style of dictation, I did want to mention this...He dictates..."I then opened a neuroforamen". To me, that is suggestive for a foraminotomy. Foraminotomy=Surgical opening or enlargement of the bony opening traversed by a nerve root as it leaves the spinal canal

    As for the facetectomy...I agree...I really don't see anything that stands out. I would query the physician. Maybe it's just a matter of adding an addendum...

  4. Default
    not possible, I work for ASC and I know I'm not going to be able to have change anything! that's I'm not sure if maybe Im safer justing billing CPT 63005 since no mention of facetectomy

  5. #5
    Location
    North Carolina
    Posts
    3,126
    Default
    If that's the case, you can only bill what's in front of you. Looks like you're stuck with 63005...

  6. Default
    thank you Rebecca!!!!!!

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