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Posterior Instrumentation & Fusion

Nicole Posted Thu 30th of August, 2018 21:08:37 PM
Patient had a previous fusion done.... Pedicle screws were placed at L2 and S1. Interspinous plates at L2-3 and L5-S1 placed previously were removed. Laminectomy/Foraminotomy/Facetectomy was performed from L1 to L5. Rods were placed and set screws were placed and tightened. As far as the procedure codes go: The laminectomy is 63047 / 63048 x4. I do have a couple questions with the above procedure: 1.) Can the codes 22612 / 22614 x4 be billed for the posterior instrumentation and fusion being done from L2-S1? 2.) Since the plates were removed from the L2-3 and L5-S1 can an instrumentation removal code be billed for that as well?
SuperCoder Answered Fri 31st of August, 2018 07:30:42 AM


Hi Nicole,


Thank you for your question.


As per the provided documentation, kindly find the below CPT® codes suggestions:


For Laminectomy/Foraminotomy/Facetectomy performed from L1 to L5

63047 and 63048 X 4

For posterior instrumentation at L2-S1

Segmental- 22842      

For posterior fusion at L2-S1

22612, 22614 X 3 (as the levels are- L2-L3, L3-L4, L4-L5, L5-S1)


Note: Do not report the reinsertion or removal procedures in addition to the insertion of the new instrumentation.


Hope it helps.

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