Neurosurgery Coding Alert

Question: In a patient with a postoperative Diagnosis of HNP/stenosis L3-4 and L4-5, our surgeon did the following procedures: 

1.Laminectomy L3-4 with foraminotomy and microdiscectomy L3-4 and L4-5
2.Bone dowel facet fusion L3-4 and L4-5 bilateral
3.Posterior lateral arthrodesis L3-4 and L4-5 utilizing same side autologous bone demineralized bone matrix

The operative note reads as follows: 

“After adequate general anesthesia, patient was placed in the prone position. Fluoroscopic localization was obtained at the L3-4 level. A midline incision was made and dissection carried sharply to the level of the lumbar fascia. A self-retaining retractor was placed and cutting electrocautery current was used to dissect the muscles in a subperiosteal plane bilaterally. The McCoullough retractor was then placed. The operating microscopre was brought into the field. At this point, it was noted there was no spinous process of L4 or L5. The L3 spinous process was dissected free. Under microscopic control, the high speed drill was used in order to thin the lamina at L3. Kerrison rongeurs were then used in order to perform a bilateral hemilaminectomy at L3-4 to the level of the insertion of the ligament. The ligament was tented with a blunt hook and sharply removed with the micro-Kerrison rongeurs in order to widely expose the thecal sac at this level. With no spinous process at L4, the L3 spinous process was very loose with the bilateral decompression as noted and the spinous process was then simply removed. Utilizing the Fusibone instrumentation the facets were identified, reamed and a 5 mm finned bone dowel was tapped into position bilaterally at L3-4 and at L4-5. Once the decompression was completed on the left side, attention was then directed to the right. L3-4 was decompressed uneventfully. As we continued to decompress L4-5, we encountered a significant amount of epidural fibrosis and scar from the old case. There was significant old rent in the dura with arachnoid peaking through. There was no definite CSF leak encountered. This area was covered with Duragen in order to reseal and protect and try to guard against a CSF leak. Once the decompression was adequately completed, a bone mill was used to grind up all of the same side autologous bone. This was mixed with demineralized matrix and packed out laterally in an attempt to achieve posterior lateral arthrodesis at L3-4 and L4-5.Good hemostasis was evident.”

What are the best codes to report these procedures?

Codify Subscriber

Answer: For the posterolateral arthrodesis, you report codes 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with lateral transverse technique, when performed]) for L3-4 and +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) for L4-5.

Although the introductory summary describes performing L3-4 and L4-5 discectomies with foraminotomies, the body of the operative note does not describe performance of either of these.  Assuming that you provided an excerpt of the body of the op note and that the physician performed a primary decompression for stenosis with laminectomy and foraminotomy, you would submit codes 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) for the L3-4 level, single vertebral segment; lumbar and +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]) for the L4-5 level. You do not need to append modifier 59 (Distinct procedural service) to each of these codes as they are considered separate from the arthrodesis.

Performance of the facet fusion including placement of the bone grafts and imaging is typically reported with Category III code 0221T (Placement of a posterior intrafacet implant[s], unilateral or bilateral, including imaging and placement of bone graft[s] or synthetic device[s], single level; lumbar).  However, a posterolateral fusion includes intertransverse as well as facet arthrodesis.  Since an intertransverse fusion was also performed, the additional facet fusion would not be separately reported.

You also submit codes +20936 (Autograft for spine surgery only [includes harvesting the graft]; local [e.g., ribs, spinous process, or laminar fragments] obtained from same incision [List separately in addition to code for primary procedure]) and +20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only [List separately in addition to code for primary procedure]) for the grafts.  Although use of the operating microscope was described, the operative note did not include mention of microdissection with the microscope. Unless this is included, the documentation does not support reporting 69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]).