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Thread: Neurosurgery coding help

  1. #1

    Default Neurosurgery coding help

    AAPC: Back to School
    I would appreciate any help or opinions on how to code this surgery. I have included a condensed version of it. Thanks

    Diagnosis: Displacement of posterior interbody fusion cage

    Procedure: Revision of PLIF, removal/replace of interbody cage, augmentation of PLIF with allograft and autologous bone marrow aspirate, aspiration of iliac crest bone marrow through separate incision

    Incision was made in the old scar plane posteriorly. The posterior rod was removed. Dissection was carried out to capture the cage and remove it. The endplates were denuded again. A devex trial was then placed into the interspace. Aspiration of the iliac crest bone marrow was undertaken and utilized to saturate allograft which was packed densely into the cage. Devex cage was then placed into the interspace. The rod was then placed and caps were torqued at the L3,L4, L5 segments.

  2. #2


    Your diagnosis code will be loosening of implant (a complication code, 99x.xx), since there was a fusion use v45.4 also. For CPT's your doc is doing a removal of implant (look in the 20000 sec of CPT) along with, essentially, a re-fusion with bone marrow graft and posterior segmental insturmentation...on a sesame seed bun.

    See what codes you come up with and post them. The folks here are good and will let you know how you did, along with why!!

    Bruce Crandall, CPC
    North Carolina Specialty Hospital
    Durham, NC

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