Question: I received an operative report that stated the following:
1. L5 partial laminotomy, partial foraminotomy, partial facetotomy
2. S1 partial laminotomy, partial foraminotomy, partial facetotomy
3. exploration of L4-5 decompression
4. irrigation and aggressive debridement of back wound both superficial and deep.
What codes should I report?
Wisconsin Subscriber
Answer: For the re-exploration of L4-5, you should report 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy, and/or excision of herniated intervertebral disk, re-exploration, single interspace; lumbar).
For the L5-S1 laminotomy, foraminotomy and facetotomy, you should report 63047 (Laminectomy, facetectomy and foraminotomy, [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar).
