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Orthopedic Coding Alert

Reader Questions:

Use Add-On Codes to Account for All TLIF Codes

Published on Mon Feb 21, 2011

Question: During the same operative session, the orthopedic surgeon performed the following procedures: L4-L5 diskectomy, L5-S1 diskectomy, L4-L5 transforaminal interbody fusion using posterior interbody technique, L5-S1 transforaminal interbody fusion using posterior interbody technique, bone graft placement (local autograft), L4-L5 interbody cage placement, L5-S1 cage placement and L4, L5, S1 bilateral pedicle screw instrumentation. How should I report this encounter? Answer: From the description you provide, your surgeon likely performed a transforaminal lumbar interbody fusion (TLIF) procedure. On your claim, report the following: 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy to prepare interspace [other than for decompression], single interspace; lumbar) for the L4-L5 arthrodesis +20936 (Autograft for spine surgery only [includes harvesting the graft]; local [e.g., ribs, spinuous process, or laminar fragments] obtained from the same incision [List separately in addition to code for primary procedure]) for the autograft +22632 (... each additional interspace [List separately in addition to [...]
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