I only code a couple spine surgeries a year, so sort of at a loss here. Any help is appreciated. The patient had a previous LEFT sided L5-S1 Diskectomy with laminotomy and foraminotomy for HNP L5-S1.
A year later, he now had a "Repeat discectomy left sided L5-S1 with foraminotomy and laminotomy. Lysis of adhesions. " AND RIGHT Sided diskectomy with laminotomy and foraminotomy. The OP note is hard to read, with many transcription errors (that will need to be fixed). But bascially, all that was done on the LEFT side was lysis of adhesions. Here’s that portion of the OP Note:

"Scar tissue present was removed. The dura was visualized above and below previous surgical site. Some adhesion between the nerve roots was also identified and released. Feel adequate safe interval to perform the discectomy through the scar tissue therefore attention was turned to the right side."

Is this enough for 63042 ? I can’t tell if a laminotomy and/or foramintomy was actually done. Diskectomy wasn’t done.

The RIGHT side looks like a straightforward laminotomy with diskectomy – 63030. It’s the "repeat" procedure I’m stuck on.

Thanks,
Cindy