Neurosurgery Coding Alert

Question: How should I report the removal of pseudoarthrosis with a redo laminotomy?

Nevada Subscriber

 
Answer: Report the laminotomy with the appropriate code from the 63040-63044 series (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, reexploration, single interspace), depending on the level. For the extra effort involved in removing the prior fusion, report 22830 (exploration of spinal fusion) with modifier -51 (multiple procedures). If posterior instrumentation was also removed, this may be reported with 22852-51 (removal of posterior segmental instrumentation).

 
-- Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.