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Reexploration & rem hardware,extention decomp L3-L4,fusion, and instrumentation

Candy Posted Mon 08th of October, 2012 23:07:38 PM

Please help with the following op report.
Patient positioned prone over chest rolls w/ flexion of lumbar spine. Skin incision made over previous scar and scar tissue excised. Incision extended upward for abour an inch and half under the L2 and L3 spinous processes and the decompression areas were exposed and self-retaining retractors applied. The thoracolumbar facia was incised on either side of L2, L3, L4, L5, S1, and S2 spinous processes an paraspinal muscles were retracted. The traverse process of L3 was dissected out and prepared for fusion by decortication. The hardware from L4-S1 was removed and the fusion explored. The pedicle screws came out very easily because of the loosening of the screws from pseudoarthrosis. The posterlateral area was explored for the previous fusion and the fusion was almost nonexistent. Interbody fusion was not specifically tested because of the difficulty to testing interbody fusion. Overall, it was felt that the patients fusion was not adequate. L3, L4, L5, and partial S1 laminectomies were done followed by L3-L4, L4-L5, and L5-S1 partial facetectomy, and foraminotomy. This involved removal of residual lamina and part of the facets and enlarging the foramina in order to decompress the dural sac and the nerve roots. This also involved meticulous neurolysis of L3,L4,L5, and S1 nerve roots bilaterally. Most of the scar tissue was excised except for some dense scarring over the dorsum of the dura, which was not neural compression. The bone that was harvested was cleared of soft tissue and saved as graft material after morselized it and mixing it with the bone marrow aspirated from the right iliac crest. The instrumentation was then done from L3-S1 using the Unimax system under fluoroscopy. After achieving hemostasis, the wound was irrigated w/ antibiotic saline using Pulsavac. Next in the inertraverse fusion was done from L3-L4 on both sides followed by posterlateral fusion also from L3-L4 on both sides. The L-4-S1 area was augmented using autograft and bone marrow. Overall the decompression, instrumentation, and fusion were found to be satisfactory. '63047','63048','20680','22852', '20936','22612','22842','22830','22614' x2, '38220'

SuperCoder Answered Tue 09th of October, 2012 20:01:16 PM


SuperCoder Answered Fri 12th of October, 2012 21:40:34 PM

If the surgeon removed the screws but didn't insert new ones, you have two coding choices depending on the original procedure. Code with 22852 (Removal of posterior segmental instrumentation) if the iliac screws were part of a previous lumbar-spinal fusion. If the iliac screws were for an old pelvic fracture, your most likely choice is 20680 (Removal of implant; deep [e.g., buried wire, pin, screw, metal band, nail, rod or plate]). Append modifier 52 (Reduced services) to the procedure code to indicate the surgeon didn't remove all instrumentation. If, however, the surgeon inserted new screws, report 22849 (Reinsertion of spinal fixation device). No modifiers or other codes are necessary.

Explanation: Surgeons sometimes use iliac screws during spinal fusion cases to anchor or attach plates or rods going up to the lumbar spine. CPT includes specific codes for spinal instrumentation insertion and removal and your example definitely involves deep hardware. Because of this, you would report 22852 for the case in question instead of 20680.

Bone marrow aspiration will not be coded separately as it gets bundled into 63047/63048/22612/22614

Your final codes will be

You can't bill instrumentation removal during repeat fusions

Suppose your surgeon places segmental instrumentation during a spinal fusion, but a year later the patient returns complaining of severe low back pain, and the surgeon suspects pseudarthrosis.

The surgeon returns the patient to the operating room (OR), removes the instrumentation and explores the fusion mass (22830, Exploration of spinal fusion). The orthopedic surgeon confirms pseudarthrosis and performs a redo fusion.

"Some Medicare carriers say you can't use the instrumentation removal codes with 22830," said Greg Przybylski, MD, professor and director of neurosurgery at the NJ Neuroscience Institute at JFK Medical Center and Seton Hall University, at a May Coding Institute audioconference titled "Eight Stellar Strategies for Spine Surgery Pay-up."

Those Medicare payers are wrong, Przybylski says. "CPT added language in 2005 that states the AMA's position, which is that you can use the instrumentation removal/reinsertion codes with 22830."

The applicable removal/reinsertion codes you should report are:

•22849 - Reinsertion of spinal fixation device

•22850 - Removal of posterior nonsegmental instrumentation (e.g., Harrington rod)

•22852 - Removal of posterior segmental instrumentation

•22855 - Removal of anterior instrumentation.

Justification: CPT states, "Report modifier 51 (Multiple procedures) with 22849, 22850, 22852 and 22855 when instrumentation reinsertion or removal is reported with other definitive procedures such as arthrodesis, decompression, and exploration of fusion."

If your insurer continues to deny your instrumentation removal claims when you report spinal fusion, copy the applicable page of CPT (the notation is printed directly above code 22830's descriptor) and send it with your appeal, along with a short letter from the surgeon.

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