# Spine anyone?



## RebeccaWoodward* (May 26, 2009)

Below was coded as 63056 and 63030.  There aren't any NCCI edits against these two codes.  The carrier has denied 63030 as inclusive into 63056.  The surgeon feels strongly that these are separate, billable codes.  I would really appreciate any input….Thanks! 


PREPROCEDURE DIAGNOSIS:  Right L4-5 disk bulge with intra and extraspinal potential nerve root compression.

POSTPROCEDURE DIAGNOSIS:  Right L4-5 disk bulge with intra and extraspinal potential nerve root compression with intraspinal subligamentous disk herniation, far lateral disk bulge.

PROCEDURE:  Intra and extraspinal approach to right L4-5 disk space with intra and extraspinal diskectomy, decompression of L4 and L5 nerve roots.  Minimally invasive approach utilizing Medtronic METRx system.

SPECIAL PROCEDURES:  Fluoroscopy for less than 60 minutes, replacement of operative portal and operative microscope for microdissection.

PROCEDURE:  The patient was brought to the operating room, intubated in her own bed, and induced under general anesthesia.  She was then turned into a prone position on the spine table and positioned according to protocol.  Thromboguards had been placed.  Her back was prepped and draped in the usual fashion.  Fluoroscopy was instituted, and initially on the AP view the right L4-5 facet was localized and cannulated with a spinal needle.  Then under the lateral view this was confirmed to be the L4-5 disk space.  A paraspinal incision was made, and the Medtronic METRx tubular system was used to dilate an operative portal down to the right L4-5 region.  Dissection was carried out both in the interlaminar region but also on the lateral aspect of the facet joint, anticipating both and intra and extraspinal approach.  A 26 mm tube was eventually docked on the right-hand side centered over the more medial aspect of the L4-5 disk space.  This was confirmed with both AP and lateral fluoroscopic images and was demonstrated to be in excellent position.  

The fluoroscopy was removed and operative microscope brought into field.  Further soft tissue was reflected off the interlaminar space, which was nicely exposed.  A combination of drill and Kerrison rongeurs was used to carry out a hemilaminotomy and foraminotomy, and the lateral ligamentum flavum was resected.  An up-angled 2 mm Kerrison was used to alleviate the lateral recess stenosis, taking care to preserve the _______________ aspect of the facet joint given the anticipated far lateral approach as well.  This was nicely accomplished.  The L5 nerve root was well decompressed with the foraminotomy as well.  The L5 nerve root was identified and mobilized gently medially.  As we reached the level of the disk space there was a sizeable, almost reducible bulge there.  The L5 nerve root and thecal sac were held gently medially with cottonoid patties.  The annulus was incised with an 11 blade knife, and a sizable piece of both nucleus polyposis and endplate teased out from underneath the annulus laterally.  This was a partially extruded fragment, though it had not completely come through the annulus itself.  A routine diskectomy was performed removing all loose and degenerative disk material with a combination of gentle curettage and pituitary rongeurs.  Special attention was directed laterally underneath the facet joint, using back-angle Kerrison and pituitary rongeurs to remove as much disk material from there as possible.  The L5 nerve root was nicely decompressed.  With a long nerve root hook as well as a dental instrument, I could palpate the more lateral annulus underneath the facet joint.  It still felt somewhat tight, and I proceeded with the extraspinal approach as anticipated.  

The tube was repositioned more laterally, exposing the very lateral aspect of the L4-5 facet.  A combination of drill and 1 and 2 mm Kerrison rongeurs as well as the up-angle Kerrison rongeur was used to expose the lateral aspect of the disk space.  The L4 nerve root was identified and was noted to almost be medially displaced, certainly much more medial than what we usually see.  I was able to gently mobilize it a little more laterally, and there was a very large prominent bulge from the 
L4-5 disk space far laterally, which had been displacing the L4 nerve root somewhat medially.  This was incised and another piece of endplate and annulus was removed from the far lateral aspect of the disk space with marked relaxation of the L4 nerve root and resumption of its normal more lateral position.  The disk space was entered from the far lateral side, and a few other small pieces of disks could be removed.  

Attention was then directed back towards medially, and we reexplored there to be sure that we had not pushed anything from lateral to medial, and that was negative.  

At this point the L4 and L5 nerve roots were nicely decompressed.  The facet joint was left intact.  It was noted to be slightly hypermobile, but again left intact.  The disk space was irrigated from intraspinal to extraspinal and then reexplored for any further loose pieces of disk, and this was negative as well.  Bony edges were curetted until smooth and waxed with bone wax.  Valsalva was performed.  There was no evidence of CSF leak.  Surgicel was left overlying the dura where it approximated bone, and then 1 mL of 40 mg/mL Depo-Medrol was introduced into the epidural and extraspinal _______________ over the nerve roots.  As the tubular retractor was slowly withdrawn, hemostasis was achieved.  The wound was subsequently closed with Vicryl for fascial and subcutaneous closure and skin staples for skin apposition.


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## magnolia1 (May 26, 2009)

I don't come across any edits for these two codes either.

If you feel strongly that your documentation supports two different approaches, appeal it.


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## RebeccaWoodward* (May 26, 2009)

Well...I have. Yet, it denied again for bundling issues.  The carrier claims it follows CMS edits and states that these two procedures are mutually exclusive.  I have checked with CMS again and nothing........  Now...this carrier has this fancy editing feature, online, and their editing software bundles these two services together. Looks like we'll be taking this to provider review.


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## magnolia1 (May 26, 2009)

Have you provided them with the link to the CMS website that shows these two procedures are not mutually exclusive?


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## RebeccaWoodward* (May 26, 2009)

I'm in the process of getting all this lined up.  Once we get the 2nd appeal written out, I'm going to reference this information.  I just find it hypocritical since their site clearly indicates they follow CMS guidelines.  This is a rather large carrier so I take it that this has become a method of not paying our claim with hopes we'll go away.............


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## magnolia1 (May 26, 2009)

I hear ya sister!


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## mitchellde (May 26, 2009)

Rebecca,
we always used code correct to check the edits, then we took screen shots of the page showing the edits or the statement that there are no edits and provided this as our proof and it has always been accepted, you will need to take an actual screen shot of the CCI page that shows this is not mutually exclusive, also ask them which version they are using, the edit version you use must correspond to the date of the visit, this could be extremely key to your case.  Let me know if you need help.


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## jira85 (Jun 8, 2009)

*Medtronic states...*

Our practice has had this same problem- and so we asked for a review from Medtronic- who specializes in Spinal Care. This is what they had to say...

"Codes 63030 and 63056 should not be reported together unless they are performed through separate incisions on separate areas of the spine.  Both of these codes are for a discectomy but each represent a different approach.  Although there is not a CCI edit, when both of these codes are reported it is considered double coding for the same procedure.  This code is being investigated by AMA and CMS because of a recent spike in its reporting without any new technique associated with it."


I hope that this helps clarify for the doctor, we've stopped billing the two together until further updates.


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## RebeccaWoodward* (Jun 8, 2009)

Thank you for replying to this!!  I, too, emailed the Spine Line about a week ago.  They confirmed exactly what you said. This wasn't what my surgeons wanted to hear.....   Like them, we learn something new everyday.  

Thanks again!


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