Question: A surgeon performed a bilateral hemilaminectomy with diskectomy and foraminotomy for nerve decompression. He then performed a lumbar decompression with posterior lumbar interbody fusion and posterior lateral transverse fusion with pedicular screws. How should I report this?
Tennessee Subscriber
Answer: First, you shouldn’t consider the hemilaminectomy with decompression part of the fusion (although more payers are beginning to bundle these procedures). Report 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]) for this part of the surgery. Be sure to append modifier 50 (Bilateral procedure) to indicate that the hemilaminectomy was bilateral.
Next, report the posterior lumbar interbody fusion (PLIF), in which the vertebral endplates are separated and graft material inserted between them, using 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar).
Note: Because the National Correct Coding Initiative bundles 63030 and 22630, you’ll have to append modifier 59 (Distinct procedural service) to 63030. Be sure the documentation supports reporting the procedures separately. Different diagnoses or different incisions are examples of why you’d report both procedures.
Report the fusion using 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]). Attach modifier 51 (Multiple procedures) to 22612 because the physician performed both the PLIF and posterior lateral transverse fusion.
Remember: You need to report the instrumentation as well. If the surgeon performed a single-level instrumentation (i.e., two adjacent vertebrae), you should assign 22840 (Posterior non-segmental instrumentation [e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation]).
If the physician performed a two-level (i.e., three-segment) instrumentation attached at L4, L5 and S1, you should report 22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and subliminal wires]; 3 to 6 vertebral segments).
If he placed the pedicle screws and attached the instrumentation at only two places, 22840 would be correct regardless of how many levels are between the endpoints.
