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sacral chordoma case

Steve Posted Tue 14th of October, 2014 14:01:27 PM

How to code?
Sacral Chordoma case?
Spinal cord, sacral tumor, lumbar laminectomy.

SuperCoder Answered Wed 15th of October, 2014 05:22:22 AM

Thanks for your query. !!

Please provide us more details. Exact diagnosis and the procedures that provider performed.

Steve Posted Wed 15th of October, 2014 11:04:35 AM

PREOPERATIVE DIAGNOSIS: Sacral chordoma.

POSTOPERATIVE DIAGNOSIS: Sacral chordoma.

OPERATIVE PROCEDURE:
S1, S2 and S3 bilateral laminectomy and foraminotomy.
Ligation of bilateral S4 and S5 nerve roots.
En bloc resection of sacral chordoma including distal sacrum below the S3 level, large sacral and presacral mass.
Neurolysis of bilateral sciatic and pudendal nerves.
Intraoperative spinal neuronavigation guided tumor resection.

SuperCoder Answered Sun 19th of October, 2014 23:34:02 PM

Based on the information provided, please find the answer below:

POSTOPERATIVE DIAGNOSIS: Sacral chordoma. 170.6, Malignant neoplasm of pelvic bones sacrum and coccyx

OPERATIVE PROCEDURE:
-S1, S2 and S3 bilateral laminectomy and foraminotomy. 63011-50,22.

63011 represents 'Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; sacral'. Modifier 22, increased procedural service is used to indicate additional work involved in doing foraminotomy.

-Ligation of bilateral S4 and S5 nerve roots. (Included in other procedures)

- En bloc resection of sacral chordoma including distal sacrum below the S3 level, large sacral and presacral mass. Code 49215, Excision of presacral or sacrococcygeal tumor,

- Neurolysis of bilateral sciatic and pudendal nerves. Code 64712-50

Code 64712 represents 'Neuroplasty, major peripheral nerve, arm or leg, open; sciatic nerve'.

For pudendal nerve neurolysis use code 64722,Decompression; unspecified nerve(s) (specify).

-Intraoperative spinal neuronavigation guided tumor resection. Code 61783-59.
Code 61783 represent 'Stereotactic computer-assisted (navigational) procedure; spinal (List separately in addition to code for primary procedure)'.

Thanks !!

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