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Wiki Neurosurgery
- Thread starter ckirkp1
- Start date
RebeccaWoodward*
True Blue
My doctor did a laminotomy and medial facetectomy with foraminotomies and nerve root decompression of the L5-S1. The patient has a herniated disk and radiculopathy. Can I use 63048 for the S1? Thanks for anyones help.
Only if the physician clearly documents in the op note that both the L5 and S1 root pairs are seen. Our neurosurgeons document this carefully in the event I need to appeal. In the event you should need to appeal, keep this bulletin handy from the AAOS. I have won appeals upon submission of this bulletin along with a letter of explanation.
For example, if just the L5 roots are seen with an L4/L5 lami, 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” would be reported. If both the L4 and L5 root pairs are seen in this procedure, codes 63047 and 63048 would be used. The documentation must support the root levels being decompressed
http://www2.aaos.org/aaos/archives/bulletin/aug04/code.htm
RebeccaWoodward*
True Blue
Anytime~