# Neurosurgery - My surgeon scheuduled a patient



## mbabou (Jan 28, 2010)

My surgeon scheuduled a patient for a Posterior Lateral Fusion with Decompressive Laminectomy with Non-segmental Instrumentation and harvest of bone graft.  On the day of surgery, he did a decompression and harvested the bone graft and discontinued the procedure when he reached the pedicles realizing that the planned instrumentation would not be adequate to complete the surgery.  He stored the bone graft in subcutaneous tissue and closed.   The next day, he went back to the OR and placed the instrumentation and placed the bone graft and proceded with the fusion.  Any recommendations regarding the modifiers and CPT codes that can actually be paid?  I guess I would use 22612, 22614, 22840, 63047-59, 20936, and 20930 but I'm really unsure where to place modifiers or what modifiers to use. I am unsure about modifier 59 as decompression and fusion were done on 2 separate days.  Any help appreciated.


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## RebeccaWoodward* (Jan 29, 2010)

mbabou said:


> My surgeon scheuduled a patient for a Posterior Lateral Fusion with Decompressive Laminectomy with Non-segmental Instrumentation and harvest of bone graft.  On the day of surgery, he did a decompression and harvested the bone graft and discontinued the procedure when he reached the pedicles realizing that the planned instrumentation would not be adequate to complete the surgery.  He stored the bone graft in subcutaneous tissue and closed.   The next day, he went back to the OR and placed the instrumentation and placed the bone graft and proceded with the fusion.  Any recommendations regarding the modifiers and CPT codes that can actually be paid?  I guess I would use 22612, 22614, 22840, 63047-59, 20936, and 20930 but I'm really unsure where to place modifiers or what modifiers to use. I am unsure about modifier 59 as decompression and fusion were done on 2 separate days.  Any help appreciated.



Based solely on what you posted...

Day one:  63047
Day two:  22612 22614 22840 20936 20930 and *58* (staged procedure) as your modifier since he couldn't complete the surgery on day one and made the decision to complete the more extensive procedure on day two....at least, that's what I would do.


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## mbabou (Jan 29, 2010)

Thank you for the reply Rebecca.  That sounds appropriate to me too, I'll give it a try.


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## Rivero (Jul 1, 2010)

What if the surgeon performs the posterior non-segmental instrumentation one day and performs the fusion on the following day?  How are we to code the instrumentation if none of the corresponding primary CPT codes apply on that first day of surgery?  My surgeon states the situation is analagous to the "growing rod" operation....Any feedback would be fully appreciated....


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## RebeccaWoodward* (Jul 7, 2010)

Rivero said:


> What if the surgeon performs the posterior non-segmental instrumentation one day and performs the fusion on the following day?  How are we to code the instrumentation if none of the corresponding primary CPT codes apply on that first day of surgery?  My surgeon states the situation is analagous to the "growing rod" operation....Any feedback would be fully appreciated....



Interesting...can you post the scrubbed op note(s)


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## Rivero (Jul 23, 2010)

*Operative note*

Preoperative Diagnosis:
Scoliosis,spondylosis,nerve root compression,and out-of-balance deformity.

Procedures:
Application and removal of Mayfield headholder,exploration of spinal fusion T10to L3, placement of pedicle screws T11 to S1, preparation of lumbar spine for arthrodesis L1 through S1, and placement of temporary distraction nonsegmental instrumentation, T10 to L3.

Indications:
This is a 54-year-old patient who had previously undergone Harrington instrumentation and fusion followed by removal of broken Harringtion instrumentation.  She has had progressive low back pain with intermittent right sciatica and is dissastisfied with her out-of-balance deformity...together we elected for a staged procedure with a posterior decompression and partial instrumentation placement and osteotomies on day #1 followed by planned anterior interbody fusion of lumbosacral spine followed by completion of instrumentation and fusion.....In this report, I will dictate the exposure of the spine, exploration of spinal fusion, placement of screws, and preparation of the lumbar spine for arthrodesis.

Procedure in Detail:
After induction of general anesthesia, the scalp was prepped and a 3-point headholder was applied.  The patient was now turned and positioned prone on the four-poster frame.  She was prepped and draped in usual fashion.  The previous midline incision was opened in its distal portion and then extended down to include the lumbar spine.  The incision was carried down to the spinal fusion mass which was exposed up to the T10 level.  It was found to be intact to inspection, both visual and with applied manual pressure.  In fact, it was quite an abundant fusion mass.  The lumbar spine and S1 was exposed as well out to the tips of transverse processes from L2 through L5 and the sacral ala was exposed bilaterally.  The transverse processes and sacral ala were decorticated with Midas Rex bur.  Next, with AP fluoroscopy, we began the placement of the screws beginning at the T11 level and working our way all the way down to S1.  We used AP fluoroscopy for all the levels except for S1 as well as anatomic landmarks in the lower lumbar spine; however, in the upper lumbar spine, these were all obscured by the extensive fusion mass and we were limited to using radiographic technique.  We identified the pedicle at each level...We used an awl followed by a Lenke straight probe to enter the pedicle to a depth of 20mm.  We placed temporary pedicle markers and then switched to lateral fluoroscopy.
We then tapped, probed, and placed the screws at each level.  We used polyaxial screws from the Monarch system at every level.  Dr. X now entered the room and performed osteotomies from T10 to L2 and from L4 to S1.  The L3-4 segment was noted to be quite stiff and therefore, we felt it was best not to take down the existing bone as correction of deformity was not needed at this level.  
After completion of the osteotomies, we did take a temporary rod, placing a hook in the upper osteotomy side and creating a hook site below the L2 screw and then placed a single rod to distract between these 2 hooks to get temporary correction of the deformity so as to help in loosening the spine and also planning the next stage of the procedure, which was scheduled for next week.  At this point in time, we then took the bone which had been obtained from the osteotomies and placed it after morselizing in the bone mill over the decorticated posterior elements on the concavity of the lumbar fractional curve on the patient's left-hand side.  The patient tolerated the procedure without complication.....


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