Neurosurgery Coding Alert

Question: A patient with lumbar discitis has a herniated nucleus pulposus at L3-L4; this is compressing the L4 nerve root. Local anesthesia is administered, and the patient is placed prone on the operating table. The insertion area is cleaned, and under fluoroscopic guidance, the surgeon inserts the needle through soft tissues to the intervertebral disc space L3-L4. The surgeon then attaches a syringe to the needle and removes portions of the nucleus pulposus via aspiration. The surgeon then removes the needle and places a small bandage over the injection site. How should I code this encounter?

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Answer: You’ll report this surgery with a single code: 62287 (Decompression procedure, percutaneous, of nucleus pulposus of intervertebral disc, any method utilizing needle based technique to remove disc material under fluoroscopic imaging or other form of indirect visualization, with discography and/or epidural injection(s) at the treated level(s), when performed, single or multiple levels, lumbar). This code covers any kind of guidance, discography, or epidural injection(s) that might occur during the surgery.

Don’t forget: Append M46.46 (Discitis, unspecified, lumbar region) to 62287 to represent the patient’s lumbar discitis.