Nicole Posted Wed 14th of December, 2016 16:19:17 PM
The doctor did a C1 Laminectomy (63045), Posterior Fossa Decompression (61345) and Duraplasty (20926).
Should these procedure actually be billed under CPT code 61343 (includes laminectomy and dural graft). In the dictation it does not state the doctor removed any portion of the occipital bone, which is what is stopping me from using this code.
The doc basically exposed the suboccipital along with the C1 and C2 spinous process and lamina. High speed burr was used to drill troughing the lamina bilaterally and a laminectomy was performed at the C1 level. Burr was used to trop to outline the foramen magnum and thoroughly decompress the suboccipital region. This was continued about 3.5cm above the foramen magnum and laterally to the lip of the foramen magnum on each side to excoriate thorough decompression of the foamen magnum.
Any advice would be greatly appreciated!
SuperCoder Answered Thu 15th of December, 2016 03:14:21 AM
Greetings from SuperCoder.com!
Code 61343 is more appropriate because it includes all the three - laminectomy, decompression, and duraplasty. Document says “exposed the suboccipital” and “Burr was used to trop to outline the foramen magnum and thoroughly decompress the suboccipital region”, which is enough to support code 61343. Code 20926 has CCI edit with 61343, so please do not report 20926.
Please feel free to write if you have any further questions.