Nicole Posted Tue 02nd of October, 2012 20:09:27 PM
I could use some advice coding the following dictation. I am not sure if it is a CPT code or a Category 3.
"Fluroscopic assistance was used to develop appropriate imagaing. Following this, an epidurogram was created at the level of L4-L5 on the right side. The tocar was advanced through a stab hole into the L4-L5 interspace. The tocar was tucked at the superior aspect of the L5 Lamina. Following this, the bone sculpting instrument was placed and the ligament was attempted to be released off the bone as well as a few bits of facet joints were also taken. Tisse removing instrument was used to release as much of the ligamentum flavum as we could between the two laminae in order to allow release of the ligamentum flavum. Few bits were taken from the right facet joint as well. Improved flow was documented on the right side. At this point the needle was taken out."
SuperCoder Answered Wed 03rd of October, 2012 14:17:12 PM
Answer is 0275T
CPT® does not include a code specifically for MILD, so you’ll choose between two ‘unlisted’ codes: 22899 (Unlisted procedure, spine) or 64999 (Unlisted procedure, nervous system).
Coders sometimes ask if 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar) can be used for MILD. The answer is no because of the difference in what MILD represents and the descriptor for 63030. The MILD procedure is a fluoroscopically guided needle-based approach without direct visualization of the neural structures and is not intended for removal of disc material. Code 63030, by contrast, represents an open surgical or open with endoscopic-assisted approach.
Looking ahead: A new Category III code that could apply to the MILD procedure will go into effect July 1, 2011 and will be listed in CPT® 2012. The new choice will be 0275T (Percutaneous laminotomy/laminectomy [intralaminar approach] for decompression of neural elements, [with or without ligamentous resection, discectomy, facetectomy and/or foraminotomy] any method under indirect image guidance [e.g., fluoroscopic, CT], with or without the use of an endoscope, single or multiple levels, unilateral or bilateral; lumbar). Remember, CPT® Category III guidelines state, “If a Category III code is available, this code must be reported instead of a Category I unlisted code.”