# spinal fusion help



## BFAITHFUL (Nov 6, 2008)

what do guys think of the following?

1. complete arthroscopic endoscopic disectomy via transpedicular approah at L4-L5 and L5-S1.
2.Posterior lumbar interbody fusion at L4-L5 and L5/S1
3. iliac creast bone graft.
4. local autograft
5. Allograft
6. Discogram for tissue idenfication
7. Fluoroscopic guideance
8. Bone marrow aspirate x3

Operative Procedure:

patient was identified brought to operating room under general endotracheal anesthesia. draped over the posterior lumbar spine. attention turned to right iliac crest. An incision was made over the iliac crest. The soft tissues were sharply dissected down to the fascia. The fascia was opened using Bovie cautery. Using osteotome, the ilium was opened. A bone harvesting trephine was used to harvest multiple cores of bone from the ilium. A Jamshidi needle was placed between the inner and the outer tables of the ilium and bone marow was aspired. This was done in three different areas. This was mixed with Vitoss to be used as a bone graft extender. Incision was irrigated out well. The incision was back filled with Vitoss. Attention was then turned to the discectomy. Using multiple fluroscopic views, spinalneedles were inserted transpedicularly and transforaminally into the L4-L5 and L5-S1 disc space. Indigo-carmine dye was used to perform a discogram for tissue identification purposes. This was done on the live-time fluoro. This was done in order to stain the disc blue so as to differntiate from the other neural elements. Guidewires were placed through the spinal needles and the spinal needles were then taken out. Incisions were made around the guidewires. Dilators were placed over the guidewire into disc space and working tubes were placed over the dilators. The dilators andguidwires were taken out. The endoscope was inserted. The disc spaces were inspected. Using pituitaries, articulating pituitaries, articulating curettes, rotating disc cutters, and shavers, a complete disectomy was performed at L4-L5 and L5-S1. This was sent to pathology. The endplate was dilated using the rotatin gdisc cutters. Local auto graft bone was separated from endplate cartilage and saved to be mixed with the iliac crest bone. Local autograft bone was thus harvested. The disc spaces were prepared. The Wolf tubes wre chaged for #7 spinology tubes on the right side and connected to the table mount. The appropriate sized spinology cage was selected and placed on the cage inserted. Iliac crest bone mixed with InFuse were placed in the anterior most aspect of the disc space through the tube. The cage was then placed. It was filled in the usual fashion with allograft. The cage insertion device was disconnected from the cage and the tubes were extracted . Intraoperative fluro showed excellent distraction of the disc spaces. Attention was then turned to the pedicle screw fixation. Wires were placed ito the pedicle at L4, L5, and S1 on right side. An incision was made connecting the wires, effectively creating a Wiltse approach. These were driven under multiple fluro views into the pedicles at L4, L5, and S1. These were opened with a pedicle seeker, tapped, and the appropriate sized Pathfinder pedicle screws were placed. Intraoperative neurophysiology confirmed safe placement of all screws. Intraopeartive fluro secondarily confirmed safe placement of the screws. The appropriate sized rod was controured and placed into the heads of the screws. These were locked in place using the locking end caps. The incision was irrigated out well. The transverse processes at L4 and L5 were decorticated using a rongeur and an osteotome was used to decorticate the sacral ala. The remaining iliac crest bone and autograft bone, and Vitoss mixed with bone marrow aspirate were placed into the lateral gutter on the right side. 

Here is what i think,

22630 (interbody posterior fusion) the fusion performed in the interspaces
22632 (" " 2nd level) 
22612 (posterolateral fusion) for the decortication of transverse processes accord. to AAOS and CPT asst. this is not bundled any longer 
22614 (each add'l level)
63056-59 (discectomy, transpedicular approach) although its bundled, a complete discectomy was done, it wasn't just to prepare interspace for the fusion)
63057 (ea. add'l level)
22842 (posterior segmental instrum.)
22851 (cages, @ L4-L5 & L5-S1) that was used for the synthetic cage used in the interspace
22851-59
20930 (allograft)
20936 (local autograft)
20937 (autograft from the iliac crest separate incision)
won't code 38220 bone aspirate, according to AAOS if aspiration is obtained through same incision that the autograft was obtained it shouldn't be coded
won't code 62290 discogram or 76000 as these are bundled according to CCI.

So what do you guys think?


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## Claudia Yoakum-Watson (Nov 7, 2008)

I know this is a tough one, but we have to have some good spinal coders out there who like a good challange.  Anyone have any thoughts?  Thanks.


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## BCrandall (Nov 7, 2008)

Looks fine on the coding side...don't expect full reimbursement though, you'll probably have to fight the insurance for it!


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## Claudia Yoakum-Watson (Nov 7, 2008)

I love spine surgeries because they are so challanging.  I question whether 22630-22631 or 22851 are supported.  I'm interested to hear from others. Here are my thoughts.  

Arthrodesis

How many fusions (arthrodesis) were done? I see two. L4-L5 and L5-S1. Since 22630-31 and 22612-14 are all for arthrodeses, if you report all four codes, you are indicating 4 fusions were performed. Here are my thoughts.

22630-22631 is for arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace plus one additional interspace for lumbar. Since the op note states complete diskectomies were performed, you can code the discectomies separately and would not use 22630 and 22631 because they include the discectomies. 

In my opinion, 22612-22814 would be the correct codes. 22612-22614 is for arthrodesis, posterior or posterolateral technique, single level; lumbar (with or without lateral transverse technique) plus one additional segment


22851 (cages, @ L4-L5 & L5-S1)
22851-59
This code is usually used for complete replacement of a vertebra. I think the “cages” are part of the segmental instrumentation listed above.


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