Outpatient Facility Coding Alert

Question: I could use some advice coding the following dictation:

"Fluoroscopic assistance was used to develop appropriate imaging. Following this, an epidurogram was created at the level of L4-L5 on the right side. The trocar was advanced through a stab hole into the L4-L5 interspace. The trocar was tucked at the superior aspect of the L5 Lamina. Following this, the bone sculpting instrument was placed and the ligament was attempted to be released off the bone as well as a few bits of facet joints were also taken. Tissue removing instrument was used to release as much of the ligamentum flavum as we could between the two laminae in order to allow release of the ligamentum flavum. Few bits were taken from the right facet joint as well. Improved flow was documented on the right side. At this point the needle was taken out."

Should I be focusing on reporting a CPT^® code or a Category III?

Kansas Subscriber

Answer: The correct choice is 0275T (Percutaneous laminotomy/laminectomy [intralaminar approach] for decompression of neural elements, [with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy] any method under indirect image guidance [e.g., fluoroscopic, CT], with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar). Remember, CPT® Category III guidelines state, "If a Category III code is available, this code must be reported instead of a Category I unlisted code."

Background: Code 0275T became effective July 1, 2011, and was first listed in CPT^® for 2012. Until then, your options were 22899 (Unlisted procedure, spine) or 64999 (Unlisted procedure, nervous system) because CPT® did not include a code specifically for MILD.