# synovial cyst removal



## ammontagano (May 26, 2009)

Any input would be appreciated in regards to this op note, my question is--can you bill out for the excision of the cyst or just the laminectomies?

The spinous processes and lamina were identified.  No laminar defects from previous surgery.  There was stable fusion material from the previous surgery.  The L2-L3 appeared to be arthrodesed, L3-L4 had motion, and L4-L5 was solidly arthrodesed.  I gradually take doen the scar tissue, the perineural scar tissue, some bone tissue, calcified scar tissue and calcified ligamentum flavum.  Multiple tissues were present and adherent to the dura.  Lysis of adhesions was performed by removing calcified scar tissue around the epidural space, removed from the dura.  This found to be only mild central canal stenosis with moderate to moderately severe foraminal stenosois on the right side and mild to moderate on the left side.  On the right side at L3-L4 there was found to be a moderate sized *synovial cyst *compressing not only the thecal sac but the exiting L4 nerve root.

The synovial cyst was excised appros. 2-3 ml of fluid was removed from the cyst upon excision.  Foraminotomies were performed by aggressively going into the foraminal exit zone undermining the remaining facet joint and pars interarticularis along each of the nerve root down to its corresponding foraminal exit zone in order to ensure complete decompression of the nerve root.  This was done at all 3 levels L2 through L5.

The epidural space was further explored.  I did not see any evidence of disk herniation or free fragment disk herniation.  Bone taken from the lamina and facet joints was debrided of any soft tissue and morselized and later used for bone graft material.  

**Doctor also performed a posterolateral fusion at L3-L5


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## RebeccaWoodward* (May 27, 2009)

1) Posterolateral fusion=*22612* (L3-L4) *22614* (L4-L5)

2) You will also code the laminectomy but here's where you may want to query your physician.  In my mind you have a couple of choices...63047 or 63267 since it appears that the synovial cyst is outside the dura.  The actual work of a synovial cyst excision is similar to that of 63030 and 63047.  My neurosurgeons have peformed similar procedures and opted for 63267 since the RVU's truly reflected the work that was perfomed.  I wouldn't code for the 63267 in addition to 63047/63030.

Does that help at all?


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## ammontagano (May 27, 2009)

Thanks Rebecca...those were the exact codes I wanted to go with but this was the first time my doc did a cyst excision and I needed some input.  Thanks for your help.


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## RebeccaWoodward* (May 27, 2009)

Glad I could help.  Looking back at my statement, I think I need a refresher on spelling.........


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## woowooz7 (Dec 4, 2014)

Thanks for posting this question and answer.  It was very helpful.


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