# exploration of previous spinal fusion and add additional screw fixation



## klbecker (Jun 7, 2011)

Patient previously had a Lumbar interbody fusion at L5-S1.  Dr takes patient back to OR to explore the previous spinal fusion.  He then adds additional pedicle screws to L5-S1.  Would I bill 22612 (arthrodesis, lumbar) along with 22830 (exploration) and 22840 (instrumentation)?  Any opinions are greatly appreciated.  I am new to Neuro coding.
Thanks
Kristy


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## RebeccaWoodward* (Jun 7, 2011)

I'm not sure there is enough information to provide an answer...


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## klbecker (Jun 7, 2011)

Here is the OP note

*PREOPERATIVE DIAGNOSIS: *SPONDYLOLISTHESIS

*POSTOPERATIVE DIAGNOSIS: * 
SPONDYLOLISTHESIS

*OPERATION PERFORMED:* FUSION INTERBODY POSTERIOR LUMBAR SPINE - POSTERIOR FUSION WITH PEDICLE SCREW FIXATION


*ANESTHESIA:*General

*DESCRIPTION OF PROCEDURE: * 
Patient was taken to operating room where General anesthesia was induced and the patient was turned prone onto the Jackson table. Fluoroscopy was brought in the field to identify the L5 and S1 entry points were identified on both sides using the transverse process and the lateral margin of the facet, along with the projection of the center of each pedicle on the surface on each side, and appropriate marks made with a skin marker.The surgical area including the abdomen and anterior thighs was prepped and draped in the usual manner and the final timeout was completed. At this point the right sided incision was opened over the surface projection of the L5 pedicle and extending approximately 2-1/2 cm in length.This was carried down through the subcutaneous fat to the lumbodorsal fascia which was opened sharply and dissection continued to the transverse process of L5 and the sacral ala. The Jamshidi was placed on the right at L5 at the junction between the transverse process of the the lateral margin of the facet at the mammillary process.  This was accomplished under AP fluoroscopy tilted to align with the superior endplate of L5.  This was tapped into position to the pedicle and this process was then repeated at the sacrum at the location.
This process was then repeated on the left side placing a Jamshidi first into L5 to mid pedicle and then took operable location at S1.  Alternating AP and lateral fluoroscopy, the tips of the Jamshidi Szwerc passed into the appropriate vertebral bodies.  A guidewire was placed through each Jamshidi after which each Jamshidi in turn was removed. Starting with L5 on the left, the dilator was passed over the guidewire and then the starter awl passed through this.  The 5 mm tap was then used to tap the pedicle and then a 55 mm x 6 mm screw Viper screw was passed.this was then repeated at S1 with the dilator starter awl and tap and this time a 40 mm screw was passed. The neurostimulator she was placed over the L5 screw and the stimulator electrode was placed at the central hole of the screw after that she has to the guidewire and removed.  Screw stimulation was felt to be satisfactory and this process was repeated at S1 on the left.
Attention was then turned to the right side where the right L5 screw was passed in a similar manner starting with the dilator passing over the guidewire and then the starter awl and 5 mm tap. This was then repeated at S1 with the dilator starter awl a1nd tap.  Again the insulin sheath was passed over L5 and screw stimulation was verified as be satisfactory and the process repeated at S1.  still using the guidewire the 50 mm x 6 mm Viper screw was passed at L5 and a 40 mm x 6 mm screw passed at S1.
The rod length was measured with a caliper and rod selected.  Using the rod holder each rod was passed and secured distally with the set screw once it appeared in satisfactory location.  Both AP and lateral as well as live projections were used to determine the rod length was appropriate.  When this was accomplished, the rod holder was removed and the L5 setscrew passed on each side.  The torque stabilizer was used first at S1 and then at L5 to secure the rod. The Ex-tabs were then removed with the appropriate tool.  
The fascia was closed with running 0- Quill sutures, and  the subcutaneous layer with 3-0 Quill. The skin was closed with 3-0 Quill in the subcuticular layer followed by Dermabond for the skin.  Aqua-Seal dressing was placed and the patient was awakened extubated and transported recovery room where he rested good condition with the sponge and needle count reported as correct.
-
COMPLICATIONS:  
* No complications entered in OR log *


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## penguins11 (Jun 22, 2011)

Unless I am missing part of the dictation, I do not see where the dr used any type of graft,  you can't bill a fusion code, 22612 without using any graft, it also doesnt state what was done with the previous instrumentation if anything, nor does it really reference that a previous fusion was done.  You cant bill for exploration of previous fusion if he doesnt dictate that this is what was done.  All he is really describing is placement of instrumentation, 22840, which I would be leary about billing alone as this is usually always done with a fusion, if he is removing and replacing instrumentation it would be 22849.  I would give the OR back to the physician and ask him to redictate and clarify what he actually did.


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## dianarod (Jun 30, 2011)

This sems like a instrumentation exchange. I would bill 22849. exploration is not documented, but either way medicare bundles these two codes together. Not sure about commercial carriers!


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