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Coding Help! Cervical Laminotomy C6-7-T1 with Resection Spinal Cord Tumor/Mass

Charles Posted Tue 02nd of October, 2012 20:22:31 PM

I need help coding the following Surgical Precert: ***No op report***

1. Cervical Laminotomy C6-T1 with resection of spinal cord tumor/mass
(Surgeon will be putting the bone back in with plate and screws)

Thinking the following:
Laminotomy - 63020 for C6, and 63035 for C7-T1
Screws and Plate - 22845

How to capture the resection of the spinal cord mass?
The mass extends from C6-T1

I'm thinking C6-7 63275 and C7-T1 63276? both listed with modifier 59?

Charles Posted Tue 02nd of October, 2012 20:28:49 PM

The screws and plates shouldn't be 22845, it should be 22840. Posterior approach.

SuperCoder Answered Wed 03rd of October, 2012 18:47:38 PM

The answer depends on the type of mass the doctor operated on. If the mass was a neoplasm, you should report 63275 (Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical).

If it was not a neoplasm, look at code 63265 (Laminectomy for excision of intraspinal lesion other than neoplasm, extradural; cervical). For example, this is the code you would report for excision of a synovial cyst. You should submit the diagnosis and the procedure codes via a pathology report, in case of audit.

Rest codes are correct.

Charles Posted Wed 03rd of October, 2012 19:09:50 PM

Thank you

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