Neurosurgery Coding Alert

Question: Would 63709 be appropriate for the decortication procedure below?

Pre-op/Post-op Diagnosis:

1. T12-L1 vertebral body fracture dislocation with paraplegia

2. Cerebrospinal Fluid leak due to a dural tear Operation:

3. EMG

4. Fluoroscopy

5. Wide decortications of the lamina and the transverse process from T9-L4 bilaterally.

6. Bilateral pedicle screw from T9 to T11 bilaterally and from L2 to L4 bilaterally.

7. Placement of rods

8. Jackson-pratt drain

9. Closure of the dura and the cerebrospinal fluid leak.

10. Arthrodesis using allograft.

Under general endotracheal anesthesia in the prone position on the Jackson table, the patient was placed. The prominent areas were padded. Exposure of the lamina from T9 to L4. When this was completed and exposure of the lamina and the transverse process was carried out from T9 to L4 bilaterally with a little bit of cerebrospinal fluid by dural tear at the level of the fracture at T12. The dura was closed with the muscle part with Tisseel with silk 3-0 and no evidence of the leak after this. At level T9, we put screws 4.5 mm x45 mm bilaterally except the right T11 we put 4.5 mm x 40 mm. At L2, we put screws 6.5 mm x 45 mm bilaterally and at L3-L4 we put screws 6.5 mm x 50 mm bilaterally. A pedicle screw was placed from T9 to T11 bilaterally and from L2 to L4 bilaterally. The rods were placed bilaterally. The allograft was placed on the transverse process and the lamina bilaterally after decortications of the lamina and the spinal process. A Jackson-Pratt drain was placed. Closure was carried out in the usually fashion. The patient tolerated the procedure.

California Subscriber

Answer: From the notes you've submitted, it appears that the physician performed a T9-L4 fusion because of the T12/L1 fracture. The "decortications" represent preparation of the dorsal elements of the lamina and transverse processes for a posterolateral arthrodesis. The operative report doesn't support an open reduction procedure if the surgeon happened to do one.

You would report the following codes:

• 22610 Arthrodesis, posterior or posterolateral technique, single level; thoracic (with or without lateral transverse technique) and 22614 x 6 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment (list separately in addition to code for primary procedure) for the T9-L4 posterolateral fusion.
• 22843 (Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (list separately in addition to code for primary procedure)for the posterior instrumentation
• 20930 (Allograft, morselized, or placement of osteopromotive material, for spine surgery only (list separately in addition to code for primary procedure) for the morselized allograft
• 63710 (Dural graft, spinal) or 63707 (Repair of dural/cerebrospinal fluid leak, not requiring laminectomy) for the dural graft if performed, appended with the -51 multiple procedure modifier.