Nicole Posted Wed 30th of May, 2012 19:24:15 PM
Just need some clarification with coding this dictation. Are codes: 22612, 63030, 20931, 20936, 76000 accurate? Wondering if 63030 should be replaced with 63047 & 63048. Thanks for any help!
PROCEDURE PERFORMED: Arthrodesis L5-S1; laminectomy and decompression of nerve roots L5, S1; posterolateral fusion at L5-S1, allograft, autograft, and fluoroscopy.
DETAILS OF THE OPERATION: The patient was brought into the operating room where general anesthesia was induced by the anesthesia staff. He was placed on the operating room table. Fluoroscopy was used to localize the L5-S1 interspace. A 28 mm incision was marked out on the left side. The incision was made with a #10 blade after a surgical time-out. The muscular fascia was identified. This was incised. It was extended superiorly and inferiorly. Using serial dilators from Zimmer, the L5-S1 lamina and facet complex was identified. The final 70 mm port was docked on this complex. The high-speed drill was brought in. A laminectomy was performed of L5 and then at S1. This was done in order to decompress the nerve roots. The nerve roots were well visualized. At this point, a transfacet screw from Zimmer was placed into the L5-S1 facet complex. The area was irrigated. Hemostasis was obtained. A final fluoroscopic image was obtained. The lateral facet joints as well as medial portion of the remaining lamina were then decorticated. A posterolateral fusion was now performed using allograft and autograft anteriorly at the L5-S1 level. At this point, closure was performed in layered fashion. Specimen was sent to Pathology. Estimated blood loss was less than 30 cc. Postoperatively, the patient was extubated and was seemed to be at his neurologic baseline.
SuperCoder Answered Thu 31st of May, 2012 08:15:28 AM
The appropriate CPT codes for the given scenario would be:
4.) 22851 ***** (only coded if type of allograft qualify for the 22851)
1.) 22612 - Correct code
2.) 63030 – correct code - we can’t consider 63047/63048 here, because this is one inter-space partial laminectomy.
3.) 22840 – As transfacet screw fixation was done, we need to code 22840 as well. I am surprise that why you didn’t capture the same.
4.) 22851 **** - Reporting 22851 for this case is warned (as allograft was filled in cavity of dissected interspace), but I am not able to find the type of allograft. So if you have more documentation about type of allograft, you may check the eligibility of this code.
5.) 20931/20936 – Good to go. 20936 only qualify for the grafting from same incision.
6.) As fluro is done to check and confirm the position of the arthrodesis, fluoroscopic guidance would be inclusive. Due to this reason fluro is considered as the inclusive component of most of the arthrodesis code.
Here I would like to share you that the spinal procedure have high RVU (associated dollar value) and the spinal procedure coding depends upon the approach, incision, grafting, instrumentation (as applicable) etc. As these are critical attributes in the spinal procedure, it is suggested to have proper documentation.
I am doing many of the complex spinal report everyday but surprise to navigate the given scenario. If this is the complete operative note, then the given documentation is insufficient which may impact the physician’s revenue significantly.