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Laminectomy T9, T10, T11 Help!

  1. Default Laminectomy T9, T10, T11 Help!
    Medical Coding Books
    A co-worker and I are in debate as to what is correct for the OP note below. Here is option 1: 63266, 22610, 22614 and 20936
    option 2: 63016, 22610, 22614, 20936

    Any suggestions or advice is greatly appreciated. Thank you

    Kelsey, CPC

    PREOPERATIVE DIAGNOSES: 1. Epidural abscess at T10, T11, and
    extension to T9.
    2. Diskitis at T10-T11 disk.
    3. Osteomyelitis of T10 and T11 without evidence of intraosseous
    abscess (sequestrum).

    POSTOPERATIVE DIAGNOSES: 1. Epidural abscess at T10, T11, and
    extension to T9.
    2. Diskitis at T10-T11 disk.
    3. Osteomyelitis of T10 and T11 without evidence of intraosseous
    abscess (sequestrum).

    PROCEDURES: 1. Laminectomy at T9, laminectomy at T10, laminectomy at
    2. UnInstrumented fusion with local autograft at T9-T10 and T10-T11.


    ASSISTANT: None.


    MICROBIOLOGY: Times 1.

    DRAINS: Round JP times 1.



    CONDITION: Stable.

    OPERATIVE INDICATIONS: Worsening low back pain with radiographic
    diagnosis of diskitis and osteomyelitis, but with epidural extension
    and evidence of neural compression at the level of T10-T11 due to
    epidural abscess and phlegmon with extension to more cephalad level.

    OPERATIVE DETAILS: The patient was met in the preoperative holding
    area. Her operative thoracic spine was identified and marked.
    Received antibiotics prior to the skin incision due to a protracted
    course of preoperative antibiotics. Was brought to the OR and
    positioned on the table in the prone position and all bony prominences
    well padded after the induction of general endotracheal anesthesia.
    Time taken out to identify the correct lumbar spine, and she was
    prepped with triple preparation of chlorhexidine gluconate before
    localization of the levels with spinal needles. Extensive and careful
    localization of spinal needles was undertaken, counting up from the
    sacrum with placement of multiple needles as landmarks into the lumbar
    spine, into the thoracolumbar junction and finally into the thoracic
    spine. Intraoperative CT fluoroscopy and cone beam CT reconstructions
    were obtained to finally localize the levels. Dr. X
    performed intraoperative consultation for localization of levels, and
    both Drs. X and X agreed on the initial localization
    (localization #1) from the level of T9 to T11. The skin was marked,
    and the patient was prepped and draped in the standard sterile

    The skin incision was made longitudinally with the use of a 10-blade
    scalpel, and dissection was taken down to the level of the fascia.
    Self-retaining retractors were placed and hemostasis was assured with
    the use of argon beam electrocautery and then dissection was deepened
    with the use of Bovie electrocautery and self-retaining retractors
    were placed to expose the spinous processes and lamina in sequence.
    Care was taken to identify and prefer the facette capsules at every
    level and the dissection was widened, sparing the capsules and to
    expose the lamina and the interspace at the involved levels.

    At this point, an extensive second localization was undertaken with
    the use of C-arm fluoroscopy. Multiple spinal needles were again
    replaced from the lumbar spine into the thoracolumbar junction into
    the thoracic spine, and the levels were counted from below. A curette
    was placed in the interspace, and a CoCr was placed on the spinous
    process of the involved levels, T10-T11. Dr. X again
    performed intraoperative consultation for the second and final
    localization of the operative levels. Both Drs. X and X agreed that the involved levels were identified as the T10 and T11
    interspace, T10 lamina to the T11 lamina, and the T9 lamina and T9-T10
    interspace as desired. An indelible mark was made with the use of a
    rongeur at the level of the T10-T11 interspace. Decompression was
    then undertaken with the use of a rongeur, a high-speed burr with a 4-
    mm ball tip, and the use of a #2, #3, #4 and #5 kerrison.
    Care was taken to resect all the ligamentum flavum, as well as bone of
    the lamina. Facette capsules were continued to be preserved, and a
    narrow midline decompression was undertaken and ordered to assure
    stability of the lateral stabilizing structures and facetectomy was
    not required. Intraoperative cultures were obtained, and evidence of
    the intraoperative visualization of phlegmon was confirmed. This was
    completely evacuated and irrigated. Once the dorsal midline
    decompression was undertaken, a long ball-tip probe was introduced
    into the epidural space laterally on the right side and on the left
    side and was placed ventrally onto the dorsal aspect of the vertebral
    body. It was then rotated into the ventral epidural space in order to
    ensure complete destruction of any adhesions and complete evacuation
    of any retained epidural collection. This was found to be
    satisfactory, and the epidural space was copiously irrigated at
    multiple levels with warm saline with the probe rotated and placed to
    decompress the ventral epidural space. A Penfield 4 was gently
    introduced laterally to the spinal cord and dura to the T10-T11 disk
    space to decompress any retained phlegmon or collection that was
    intradiscal. The wounds were again then copious irrigated with a
    liter of warm saline and hemostasis was assured with the use of
    hemostatic agents and bipolar cautery and bone wax. The
    decompression, as well as the evacuation of the collection was found
    to be very satisfactory in the spinal cord and dura. Those levels
    were completely decompressed. Decortication of the transverse
    processes and rib heads was undertaken, and bone graft, which was
    local autograft, and found to have no evidence of infection on gross
    inspection, was morcellized and placed in the gutters at the T9-T10
    and T10-T11 intervals. A drain was placed and the wound was closed in
    layers with the use of 1-0 Vicryl, 2-0 Vicryl and nylon sutures. The
    skin was cleansed with wet-to-dry gauze and a sterile
    dressing built up of drain sponge, Xeroform gauze, 4 x 4's, ABG pad
    and foam tape.

    The drapes were taken down. All sponge and needle counts were
    correct. There were no complications. The patient tolerated the
    procedure well and was discharged to the PACU in good condition after
    Last edited by purplescarf23; 09-14-2011 at 01:01 PM.

  2. #2
    South Denver
    I would code 63046 for T9 and 63048 x 2 for 10 and 11 - your fusion and autograft is correct

  3. Default
    Quote Originally Posted by DevonaG View Post
    I would code 63046 for T9 and 63048 x 2 for 10 and 11 - your fusion and autograft is correct
    I started out with that but he did (to me) explore that area to find the abscess. So I went to the 63016. Thank you for your advice.

    Kelsey, CPC

  4. Default
    I would not use 63046, per what I can see, he did not do a facetectomy, as a matter of fact states a facetectomy was not needed. Code 63016 seems the more appropriate code. I dont think I would use 63266 as he is placing more emphasis on the lami and decompression, he is not really stating that he is removing the lesion as the focus of the operation. I agree that 63016 is the more appropriate code.

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