Lisa Gondola
New
I am have just recently started coding for a orthopedic spine surgeon. My surgeon is doing redo decompressive laminectomy for stenosis and disc disease. In this particular example the patient has had prior discectomy at the level he is performing his redo.
My question is: The doc wants to use code 63042 with additional 63044 when appropriate. My concern is within the body of the note he isn't dictating that he removed any disc, disc material, disc spurs etc... . His typical dictation includes removal of bony overgrowth, psueopedicle, scar tissue, adhesions and or stenosis. He is resecting the facet and doing foraminotomy. Due to the conditions he is dictating I am inclined to code a 63047 with 63048 when appropriate, he disagrees.
He explores the disc every time he does his procedures. Sometimes there is disc material to extract and sometimes there isn't. He believes because he explored the disc and because there is more work involved in decompressing a redo that the 63042 is warranted. He cites the CPT description “laminotomy, with decompression of nerve roots, including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc reexploration, lumbar. Focusing on the “and/or “ to mean you can explore the disc and you may or may not end up excising disc...but you can still use the code.
Any thoughts or help on this would be appreciated.
Thanks
My question is: The doc wants to use code 63042 with additional 63044 when appropriate. My concern is within the body of the note he isn't dictating that he removed any disc, disc material, disc spurs etc... . His typical dictation includes removal of bony overgrowth, psueopedicle, scar tissue, adhesions and or stenosis. He is resecting the facet and doing foraminotomy. Due to the conditions he is dictating I am inclined to code a 63047 with 63048 when appropriate, he disagrees.
He explores the disc every time he does his procedures. Sometimes there is disc material to extract and sometimes there isn't. He believes because he explored the disc and because there is more work involved in decompressing a redo that the 63042 is warranted. He cites the CPT description “laminotomy, with decompression of nerve roots, including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc reexploration, lumbar. Focusing on the “and/or “ to mean you can explore the disc and you may or may not end up excising disc...but you can still use the code.
Any thoughts or help on this would be appreciated.
Thanks