Orthopedic Coding Alert

Question: Our surgeon did the following procedures:

1. L5 revision laminectomy 

2. L2 bilateral hemilaminotomy 

3. L3 laminectomy with lateral recess decompression and foraminotomies

4. L4 laminectomy with lateral recess decompression and foraminotomies

5. Posterolateral arthrodesis L3-L4 

6. Posterolateral arthrodesis L4-L5 

7. Local bone graft 

How do we report these?

New York Subscriber

Answer: You report code 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar) for L5 revision laminectomy and code 63030 (Laminotomy (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar) and append modifier 50 (Bilateral procedure)

You will pick up code 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], eg, spinal or lateral recess stenosis), single vertebral segment; lumbar) for the L3 laminectomy with lateral recess decompression and foraminotomies and 63048 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, 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 L4 laminectomy with lateral recess decompression and foraminotomies.

For posterolateral arthrodesis L3-L4, you report 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with lateral transverse technique, when performed]) and for posterolateral arthrodesis L4-L5, you report +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]).

Finally, report +20937 (Autograft for spine surgery only [includes harvesting the graft]; morselized [through separate skin or fascial incision] [List separately in addition to code for primary procedure]) for the local bone graft.

As per current CCI edits, you should append modifier -59 (Distinct procedural services) for both procedure codes 63042 and 63030.

For a more precise choice in codes, it is good to know if facetectomy or foraminotomy was done at L5. It is also good to know the diagnosis.