Dempsey Posted Wed 15th of June, 2016 12:15:44 PM
Surgeoon is billing 22633, 22840, 22851, 20930, 20936 and 63030-59. We denied 63030 for being in the same area and surgeon is appealing our decision. We would like to know what you think? I can't paste the portion of the op note so this is it below:
First, the lumbar spine was sterilely prepped and drapped. Jamshidi's localized the L4 and L5 pedicles for 3.5cm bilateral incisions at L4 and L5, followed by screws 7.5 x 45mm screw in L4 and L5. Nerve stimulation did not reveal breach below 20, after which time on the right side an ILLICO retractor was placed, which then enabled to complete the facetectomy, decompression, diskectomy, direct nerve root visualization of L5, and then diskectoy, scraping, sizing, and curettage which then enabled a 13 x 30 Spineology cage to be filled with local bone and Actifuse, and then malleted into the anterior distal intervertebral position and using the PEEK cage.
Once this was done it was noted that there was a small dural tear with fluid which was patched with DuraGen, as well as FloSeal and Surgicel. Following this, the lateral transverse processes were decorticated and local bone and_____ were placed into the lateral gutter, after which time the patient then had the rods placed, the end caps placed and compressed using the Spineology scre system and cap devices, followed by the application of FloSeal and vancomycin poder to the wound.
SuperCoder Answered Thu 16th of June, 2016 09:54:22 AM
I would suggest append modifier XS with Cpt 63030 instead of 59 modifier.