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Neurosurgery Coding Alert

Coding Case:

Strengthen Your Spinal Reporting With This Stepwise Approach

Published on Mon Oct 22, 2012

Consider discectomy and facetectomy bundled in interbody fusion.Spinal coding may pose a challenge as your surgeon often does more procedures than one, requiring you to proceed one step at a time to capture all services and accurately assign the codes. Let the 2-step process provided in the following case study guide you to more efficient spinal coding. Example: Take a look at this sample procedure list an operative note provided by a Missouri Neurosurgery Coding Alert reader: For a patient with a preoperative diagnosis of lumbar spondylosis, the surgeon did the following: Left L4-5, L5-S1 facetectomy with hemilaminectomy of L5 and redo decompression L5-S1 on the left L4-5, L5-S1 left transforaminal interbody arthrodesis with allograft and autograftSegmental pedicle screw instrumentation L4 to S1 bilaterally Right sided posterior and facet arthrodesis with allograft and autograftIntraoperative electrical monitoring, intraoperative 3D imagingOperative note: "The patient's lumbosacral region was prepped and draped in the [...]
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