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Neurosurgery Coding Alert

Reader Question:

Check Bundle In Device Removal and Laminectomy

Published on Tue Dec 04, 2012

Question: How do we report the procedures described in the operative note below:

"The previous intraspinous plating was dissected out, exposed, and removed. The lamina of L4 was also removed. The lamina of L5 felt mobile due to the fracture of the pedicle on the right. The diamond bur drill was then used to created bilateral troughs for bilateral laminectomy at that level. Intervening ligament of flavum at L5-S1 was cleared with Kerrison instruments to decompress the lateral recess. The foramina were re-explored on both sides of the L4-5 level and the exiting nerve roots appeared well decompressed.

At L5-S1, similar foraminal exposure and exploration was done on the left side. In that area, there actually was some posteriorly displaced bone and disk material that did appear to compromise and posteriorly displace the exiting L5 nerve root. It was felt that this was the most likely source of the recurrent radicular pain symptoms. This area was shaved down with the diamond bur drill and then the loose bone material was mobilized down and away from the exiting nerve root. Some protruding disk material far laterally in this area was also cleared with angled and straight pituitary instruments.

After these maneuvers, a dental instrument could pass easily out through the neural foramina bilaterally at both levels. The thecal sac appeared well decompressed. Hemostasis was obtained with bipolar cautery.

Entry sites were then selected for the L4, L5 and S1 levels on the left. Because the pedicle fracture involved part of the inferior pedicle at L5 on the right, a decision was made not to place a screw at that level. The screw tracts were palpated internally with the pedicle feeler and were competent. The screws were also individually stimulated with intraoperative EMG electrophysiological monitoring to document activation thresholds and preclude pedicle screw breakout and all values appeared satisfactory.

The lateral facet regions were then packed with collagen BMP sponge, Mastergraft and on the left side local bone grafting material. Because of the spondylolysis at L4 and more extensive bilateral laminectomy at that level, there was more limited surface area for bone grafting bilaterally at the L4-5 level. The screws were connected by titanium top loading rods and nuts which were tightened appropriately. A final set of AP and lateral x-rays was taken which appeared satisfactory."

Oklahoma Subscriber

Answer: Below are the codes you will report:

  • 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)
  • 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) with the -51 (Multiple procedures) modifier appended.» »
  • +22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments [List separately in addition to code for primary procedure])
  • +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure])
  • +63048 (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; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)

It is unclear what the "intraspinous plate" represents. You may be describing an interspinous fixation device. The removal of non-segmental posterior fixation was not originally intended to describe removal of an interspinous device. Since the placement of an interspinous fixation device has a distinct code from placement of segmental or non-segmental posterior fixation, removal of the interspinous plating device may be reported with the unlisted code 22899 (Unlisted procedure, spine). However, since a laminectomy at both levels would entail removal of the device incidentally, payers may consider the removal a bundled service. Alternatively, one may report the laminectomy codes 63047 and 63048 with the 22 (Increased procedural service) modifier to account for the additional work needed to remove the interspinous plate.

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