BFAITHFUL
Expert
The doctor wants to bill CPT 63030 or 63047 but I'm not
sure if instead it should be 63005? because he clearly states that he did a bilateral laminectomy but does not state a foraminotomy or a facetectomy was performed.
Please see op note below. Thank you.
DX: Spinal stenosis and right lumbar radiculopathy at L4-L5
OP NOTE:
After induction of general endotracheal anesthesia, the patient was placed into the prone posture on the Kambin frame. He was protected in appropriate areas. He did receive 1g of Ancef prior to the procedure. The level was determined with a needle and checked with
x-ray control. I then approached the spine with the midline incision.
It was carred down into the subcutaneous tissue. The fascia was opened. A subperiosteal dissection was carried out on both sides of the spinous process down to the lamina. Soft tissue was stripped on each side. Primary symptoms were to the right. Therefore, mjaority of dissection was on that side. However, I did remove the spinous
process for the laminectomy. The lamina was opened bilaterally.
Further dissection was carried out towards the right neuroforamen. I elected to keep the ligamentum flavum intact. The bony decompression had been carred out. I then opened a neuroforamen and I checked this
with a woodson. There was ample space. The wound was irrigated.
Closure was then with 2-0 Vicryl in the deep fascia. The subq tissue was closed with 3-0 undyed Vicryl
sure if instead it should be 63005? because he clearly states that he did a bilateral laminectomy but does not state a foraminotomy or a facetectomy was performed.
Please see op note below. Thank you.
DX: Spinal stenosis and right lumbar radiculopathy at L4-L5
OP NOTE:
After induction of general endotracheal anesthesia, the patient was placed into the prone posture on the Kambin frame. He was protected in appropriate areas. He did receive 1g of Ancef prior to the procedure. The level was determined with a needle and checked with
x-ray control. I then approached the spine with the midline incision.
It was carred down into the subcutaneous tissue. The fascia was opened. A subperiosteal dissection was carried out on both sides of the spinous process down to the lamina. Soft tissue was stripped on each side. Primary symptoms were to the right. Therefore, mjaority of dissection was on that side. However, I did remove the spinous
process for the laminectomy. The lamina was opened bilaterally.
Further dissection was carried out towards the right neuroforamen. I elected to keep the ligamentum flavum intact. The bony decompression had been carred out. I then opened a neuroforamen and I checked this
with a woodson. There was ample space. The wound was irrigated.
Closure was then with 2-0 Vicryl in the deep fascia. The subq tissue was closed with 3-0 undyed Vicryl
