# Neurosurgery Coding Help Please



## dmd28 (Jun 25, 2009)

Any of you experts out there care to take a look at this and see if I am on the right track?   I was just given several Neuro cases and have never coded this specialty before. I would love it if you would advise on the modifiers as well as the sequencing, and coding of course.   Sorry so lenghtly.  Your comments and advice are very appreciated.  

Pre-Op Dx:  Intractable back pain, Prior lumbar laminectomy, L3, L4, and L5. Prior posterior fusion, L3-L4, L4-L5, L5-S1.  Instrumented fusion, L4-L5. Retrolisthesis, L3 on L4. L3-L4 Herniated nucleus pulposus.  Of note, the patient denies significant leg pain.

Post-Op Dx:  The same as above. 

Operation Performed: 
1. Exploration of fusion.
2. Removal of Hardware
3. Reoperative R & L L3 Laminectomy
4. Reoperative R & L L4 Laminectomy
5. Reoperative R & L L5 Laminiectomy.
6. L3-L4 transforaminal fusion
7. L4-L5 transforaminal fusion
8. L5-S1 transforaminal interbody fusion.
9. L3-L4, L4-L5, L5-S1 interbody cage placement
10. L3-L4, L4-L5, L5-S1 Posterolateral fusion.
11. L3, L4, L5, and S1 pedicle screw fixation.

1: Surgeon and 1 assistant surgeon:  So not sure about using 62 Modifier? 
OPERATION IN DETAIL:  An elliptical incision was used to remove the patients previouse midline scar and carried down to the level of the fascia. The fascia was incised with Bovie cautery.  The paraspinous muscles were dissected out to the transvers processes and lateral fusion mass at L3, L4,L5 and S1.  The s1 ala was exposed.  The pt had previous fusion bone that was posterolaterally at L3-L4. l4-L5 and L5-S1.  Inspection of fusion revealed that there was pseudoarthrosis and nonunion at L4-L5.  L5-S1 was inspected.  There appeared to have a solid fusion, although this was uncertain.  

Reoperative right L3, L4 and L5 laminectomies were then performed in the following fashion.  A straight curette was used to dissect the scar tissue away from the surrounding bone.  High-speed drill was used to remove the pars at L3 and L4. Medial facet was removed in its entirety.  The curette was used to dissect away the nerve root from the fat and scar tissue away from the pedicle.  Decompression was carried out to the foramen.  Smith-Petersen type osteotomy was performed at L3-L4 and L4-L5 on the right to make preparation of our TLIF site.  L5-S1 scar tissue ws dissected away from the bone on the right.  Aggressive hemilaminectomy was then performed with high-speed drill and 3mm Kerrison punch.  PLIF/TLIF site was prepared on the right.  Straight curette was then used to dissect away scar tissue on th eleft side ot L3, L4, and L5.  A small amount of bone was removed with a high-speed drill at left L3, L4 and L5. Intraoperative fluoroscopy was draped and brought into the field. The pedicle screws were removed at L4 and L5.  Of note, the pedicle screws at L4 were loose.  A 7.5mm screw was placed on the left.  A 7.5mm screw was placed on the right at both L3-L4 and L4-L5.  The right L4 screw was still noted to be loose, and this was exchanged for an 8.5mm diameter pedicle screw on the right at L4. 

Those screws were all noted to have good bone purchase.  Under A/P fluoroscopy, pedicle probes were placed at L3.  Ball tip probe was used to fill for bone anteriorly and circumferentilly.  A 50mm x6.5mm pedicle screw was placed at L3.  Screw was noted to be in good position and to have excellent bony purchase.  Pedicle probes were placed through the S1 pedicle such that they went to the sacral promontory.  The 6.5mm x 50mm pedicle screws were placed bicortically under fluoroscopic guidance.  

TLIF's were then performed from the right at L3-L4 and L4-L5.  Modified PLIF/TLIF was performed at L5-S1.  By retracting the transversing nerve root slightly medially, disk annulus was incised with an 11 blade scalpel.  The #8, #9 and #10 disck shavers were used to remove disk material.  A 10mm PLIF/TLIF cage was placed at L5-S1 and 9mm cage placed at L3-L4 and L4-L5. Cage was impacted into the anterior disk space after thorough preparation of the disk space had been performed with disk shaver and a ring curette. Bone morphogenic protein was packed anterior to the cage at L4-L5 and posterior to the cage at L3-L4 and L4-S1.  Additional morselized laminectomy bone was then packed into the diskectomy site posterior to the cage. This was packed in with a small bone tamp. 

Once the cages were noted to be in good postion and the bone graft was noted to be in good position, set screws were then used to attach the rods.  Set screws were torqued to 100inch pounds.  Foraminotomies were performed at the left side at L3-L4, L4-L5 and L5-S1 doing this posterolaterally using a 3mm Kerrison punch and then dissecting the scar away from the surrounding bone medially with a strait curette and using a 3mm Kerrison punch to open the foramen. 

Crosslinks were then applied and then torqued to 18 inch pounds.  A 10mm JP drain was placed and tunneled out through a separate stab incision.  High speed drill was used to decorticate the transvers process and lateral bone at L3-L4, L4-L5 and L5-S1.  The morselized laminectomy bone mixed with bone morphogenic protein was packed on the left.  Morselized demineralized bone matrix mixed with autologous bone was packed on the right.  The 7 and 10mm JP drain had been placed and tunneled out through a separate stab incision.  Lumbar fascia was closed with running looped 0-PDS Suture.  Etc...

28030-51 has CCI edit?  Not sure if I should code this one at all. 

22612, 22614, 22614, 22630,22632,22632, 63042-LT, 63042-RT,63044,63044,63044,63044,22842,22852,22851,22851,22851.  

Thank you for your time.  I know this is a very long report. 
Dawn


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## ammontagano (Jun 26, 2009)

you are right 22830 cannot be billed because you cannot charge for an exploration if you are fusing the same spaces.
Based on your report, this is what I got:

22612
22614
22614
22630-51
22632
22632
63042-59
63044-59
63044-59
22849--don't use 22842, bill for the reinsertion of spinal device
22851
22851
22851
20936

Depending on the insurance carrier, you would use modifier AS or 80 for the assistant surgeon.  You can bill all the codes for the asst except for 20936.


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## todd5400 (Jun 26, 2009)

You can also use 20930

Mary, CPC


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## ammontagano (Jun 26, 2009)

Completely overlooked 20930, thanks Mary.


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## dmd28 (Jun 29, 2009)

Thank you all for your guidance.  I am wondering if there are any books or classes you would recommend regarding coding this specialty?  I need to get up to spead quickly on this. 

Thank you in advance,
Dawn


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