# Intraforaminal versus Extraforaminal



## coderguy1939 (Sep 30, 2010)

I'd appreciate some coding opinions for the following op report.

DX:
Lumbar stenosis
Lumbar L5 facet cyst

The patient is a 58 year old who has a longstanding history of severe leg radiculopathy.

Operation:

Skin was incised at the midline.  We used Bovie cautery to deepen the incision down to the subcutaneous tissues down to the fascia.  The fascia was incised in the midline and used the subperiosteal dissection over the spinous process and lamina of L4 and L5.  I identified the L4-L5 and L5-S1 interspaces.  We then brought in a microscope under sterile conditions.  We placed a curette in the L4-L5 interspace and obtained a lateral x-ray.  We then used  a high-speed burr to thin out the lamina of L4 and L5.  

We aligned this using the high-speed burr and then used the foward-angle curette to remove the ligamentum flavum of the leading edge of L5.  It was resected with Metzenbaum scissors in the interspace and performed a partial medial facetectomy at L4-L5.  We then identified the pedicle of L5, identified a large facet cyst adjacent to the L5 superior articular facet.  I removed this material and sent it as a specimen.  It was compressing and traversing the L5 nerve root.  I then inspected the L5 nerve root.  I did not identify any additional cystic material from this region.  There was also no evidence of ongoing compression.  I decompressed the L5 nerve root out into the L5-S1 foraminal region for lateral space.  We decompressed some additional cystic material from this region, and I identified some precipitate from the previous cortisone injections which was along the L5 nerve root.  We then irrigated copiously with antibiotic containing solution using thrombin-soaked Gelforam and patties for hemostasis.  We then palpitated with a ball-tip probe along the nerve.  There was not any ongoing pressure as it exited on to the far lateral space of L5-S1.  There was no evidence of compressive materials  in the axillary region or solder region of the L5 nerve.

The doctor then closes.

An outside coding company coded this as follows:

63047
63048
63056
69990
64714

I see the 63047 but am not sure about 63048.  My understanding is that the doctor needs to see and decompress both nerve roots to code 63047 and 63048.

Also, 63056 seems to be for the intraforaminal decompression of L5-S1 and I don't see that approach described in CPT.

Am also unsure as to why 64714 was used.

Would appreciate some expert advice.

Thanks.


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## BCrandall (Oct 13, 2010)

I agree with your review. 63047 & 63048 is for the laminectomy of L4/L5, 63048 for L5/S1, 63056 is for nerve decompression due to herniated disc and it's not supported by the note, so lose that one. 64714...Neuroplasty?? I think someone gets paid by the CPT and stuck that on!


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