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Posterior Cervical fusion & foraminotomies

  1. #1
    Red face Posterior Cervical fusion & foraminotomies
    Medical Coding Books
    Need help with coding this op report please.


    *posterior spinal fusion C2-T1

    *Left foraminotomies C2-3, C3-4, C4-5, C6-7

    On the left side, a motorized bur was used to perform foraminotomies at C2-3, C3-4, C4-5, C6-7 in the following fashion. A motorized bur was used to remove bone from the interlaminar facet joint region at each adjacent facet. Removal of the inferior articular process of the superior facet allowed visualization of the superior articular process of the inferior vertebra. This was thinned down to a fine cortical shell and removed with an angled cruet. Subsequently, a 1 mm Kerrison was used to widen the keyhole foraminotomy. Adequacy of decompression was assessed by palpation of the pedicle and tracing the nerve root out through the foramen.

    Then attention was turned to decortication. The facet joints were decorticated bilaterally. Copious amounts of autogenous iliac crest bone graft was placed in facet joint region from C2-3 through C7-T1 bilaterally. Bone graft was placed over the decorticated lamina on the right side where foraminotomies had not been performed.


  2. Default
    63045/48's for the foraminotomy, but I'm not sure there was a fusion. Was there any spinal insturmentation or plating?
    Bruce Crandall, CPC
    North Carolina Specialty Hospital
    Durham, NC

  3. #3
    Instrumentation C2-T1, right iliac crest bone graft

  4. Default
    Take a look at 226xx and 2284x section of the CPT for the fusion and instrumentation. Try 2093x for the bone graft.
    Bruce Crandall, CPC
    North Carolina Specialty Hospital
    Durham, NC

  5. #5
    North Carolina
    What about 38220 for the iliac aspiration?

  6. #6
    Thanks for all the help.

  7. Default
    I didn't see any aspiration in the note Dawn posted so I figured it was a regular iliac bone graft. The note is kinda vague...
    Bruce Crandall, CPC
    North Carolina Specialty Hospital
    Durham, NC

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