# Laminectomy w/removal of intraspinal lesion



## coderguy1939 (Jan 6, 2009)

I'd appreciate some input on the following surgery:

"Patient was placed in a prone in a Wilson frame which has distracted the maximal kyphosis.  All pressure points were well padded.  A temporary skin prep was made and a spinal needle was inserted near the L4-L5 interspace and then needle localization by flouroscopy was performed.  This helped in placing surgical incision.  Next, the needle was removed and the lumbar spine was prepped and draped in the usual sterile fashion, and based on the preoperative fluoroscopic image, about a 1-inch incision was made over the L4 and L5 interspace in the midline.  Bovie cautery was used to incise the dermis and subdermal fat and incise the lumbodorsal fascia along the spinous processes of the L4 and L5.  A Cottle elevator subperiosteally dissected the paravertebral muscles off the L4 and L5 lamina.  A self-retaining retractor was placed.  Another intraoperative flouroscopic image was taken with the needle underneath the L4 lamina.  This confirmed the surgica level.  Next, a microscope resector was brought in and a high-speed bur was used to perform a partial laminectomy removing the distal portion of L4 and proximal portion of L5 lamina.  THis laminectomy was enlarged with a Kerrison ronguer.  THe ligamentum flavum was then elevated and removed.  This revealed the thecal sac traversing L5 nerve root.  In attempts to retract the nerve root to the midline there was noted to be abundant adherance, therefore a neurlysis wa performed.  This allowed the neural structures to be retracted to the midline which revealed a large intraspinal lesion.  This was removed with a combination of curette ball-tip probes and pituitary rongeurs.  Next the disc space at L4-L5 was visualized and found to have an annular bulge.  Therfore, an annulotomy was performed and the disc material was removed with the Kerrision rongeur and angled curettes.  The disc space was then irrigated with a pressurized salline to remove any remaining loose fragments.  Once this was confirmed that there was no residual disc material that was loose, a second look around the decompression site was made to ensure that there were no missed fragments.   Once the decompression was done, there was no residual central or lateral recess or framinal stenosis and the nerve roots at L5 were free."  The bleeding was stopped, fascia closed, etc.

I'm looking at 63267, but it seems to me that something more can be coded here such as 63030.  Any help would be appreciated.


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## kibbit99 (Jan 6, 2009)

63030 bundles.  You cannot use mod 59 since it is involving the same disc as the lesion.  Your code is correct.  If the lesion was on any disc but L4 or L5, you can get away with a modifier 59.


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## RebeccaWoodward* (Jan 6, 2009)

You present an interesting scenerio. At first I thought no but I'm wavering a little now.  63267=excision by laminectomy of lesion other than herniated disc

Your op note states...... 

_"Next the disc space at L4-L5 was visualized and found to have an annular bulge. Therfore, an annulotomy was performed and the disc material was removed with the Kerrision rongeur and angled curettes"_

My thought was that the annulotomy was over and beyond 63267.  So...I asked my Neuro PA and he seemed to think it was feasible, also.  He did seem to think you would have to submit the op note for medical review.  I know that CCI edits bundle the two together; however, our provider thought it was worth a try since he understands the work that is involved.


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## coderguy1939 (Jan 9, 2009)

Thank you for your responses.  It's always appreciated.


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