Charlene Posted Thu 14th of March, 2019 13:56:47 PM
Two months earlier pt had L5 laminectomy w/decompression L5-S1. Two weeks later pt fell injuring the operative site. There was a large and complicated hematoma causing compression of the cord and nerve roots. Returning to the OR, L5 lamina was completely removed as well as S1 lamina to remove hematoma and relieve compression. The reexploration of L5 cpt is 63042. Since the S1 laminectomy is a first, would cpt 63011 be correct?
SuperCoder Answered Fri 15th of March, 2019 05:50:52 AM
In CPT 63042, provider performs laminotomy of 1 lumbar interspace with decompression of the nerve root(s), and includes a partial facetectomy, foraminotomy, and/or the excision of a herniated intervertebral disc. This procedure is a re-exploration. As per clinical basis, laminotomy, also known as hemilaminectomy or a partial laminectomy, involves removing the upper and lower portions of adjacent laminae (that is, the laminae on either side of a vertebral interspace), rather than removing the entire lamina(ae) of a single vertebra. In the procedure code 63042, the surgeon removes upper and lower portions of the laminae surrounding two adjacent vertebral interspaces. If the surgeon performs two hemilaminectomies at adjacent levels, they may choose to remove the entire lamina. Although this may look like a complete laminectomy, the procedure qualifies as two hemilaminectomies as long as the surgeon excises the intervertebral discs as well. Hence, if your surgeon is working on the adjacent portion of L5, i.e. S1, then there is no need to bill the sacral laminectomy separately, because it clinically bundled in the procedure 63042. Whereas in CPT 63011, during a laminectomy, the surgeon removes the spinous process (the bony projection on the back of the vertebrae) and one or both lamina (the broad plates of bone on either side of the spinous process that complete the "arch" of the vertebrae and enclose the spinal cord), followed by decompression of the nerves. The focus of the work is the individual vertebra and the nerve roots emanating through the foramen (passageways) on either side of the vertebra. The surgeon may perform a laminectomy on several adjacent vertebral levels depending on the condition of the patient. So, there are some common steps in both the procedures, so as per provided documentation it seems that re-exploration procedure is appropriate to bill. Also, do check the situation to append the modifier 78 (Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period).
Hope this helps!