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spine coding.... please help

  1. #1
    Location
    albuquerque
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    93
    Default spine coding.... please help
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    a midline incision was made centered over the L4-L5 interspace. the incision was carried down to skin and subcutaneous tissue. hemostasis was obtained via bovie electrocautery. Dissection was carried down to the level of fascia, and the fascia was incised on the left hand side along with the incision. dissection was carried over the spinous process of L4-L5 ligamentum flavum was dissented free from its bony attachments and removed in its entirety. portion of the inferios aspect of the L4 lamina was removed and a portion of the superior lamina of L5 was removed. a portion of the superior articular process of L5 was removed to gain access to the neural foramen. the nerve root was retracted medially. A stellate incision was made n the annulus and a large disc fragment emanated form underneath the annulus. This was removed with pituitary rongeour. additional smaller fragments were removed from within the disc space once the decompression had been performed and the discectomy completed the nerve root was felt to be completely free. a 60mm amniofix dural barrier was then placed over the exposed nerve roots and dura a 0.5 vancomycin powder was spread throughout the wound during closure. the fascia was closed and the skin closed with staples
    please help!
    Angelica Stephens RHIT, CPMA, COSC, CCS-P, CPC, COC.
    Albuquerque, NM

  2. Default
    Would need to know the purpose of the decompression, was the procedure done for stenosis or because of the disc herniation?

  3. #3
    Location
    albuquerque
    Posts
    93
    Default
    herniation
    Angelica Stephens RHIT, CPMA, COSC, CCS-P, CPC, COC.
    Albuquerque, NM

  4. Default
    I would code 63030, no additional levels, this is billed per segment.

  5. #5
    Location
    albuquerque
    Posts
    93
    Default
    thank you this was billed as 63030 with 63710 and i am having a difficult time getting my point across oh how i disagree with the second code
    Angelica Stephens RHIT, CPMA, COSC, CCS-P, CPC, COC.
    Albuquerque, NM

  6. Default
    Your welcome, I actually meant billed per interspace not per segment. The dural graft code would not be at all correct. Doesnt even really say that I can see that there was a dural tear. Even if there was a dural tear that the surgeon caused we are told at the AANS seminars not to bill this separate, if you open it, it is your job to close it, code 63030 is valued for minor problems occuring during the surgery.

  7. #7
    Location
    albuquerque
    Posts
    93
    Default
    that is exactly what i know
    thanks again
    Angelica Stephens RHIT, CPMA, COSC, CCS-P, CPC, COC.
    Albuquerque, NM

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