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Click here for more sample CPC practice exam questions and answers with full rationale

Exploration of laminectomy

Hoping someone could help me figure out what CPT code to use for this! A patient is a week status post cervical laminectomy for resection of intramedullary ependymoma. The patient has to have another surgery. This surgery is an exploration of cervical laminectomy and resection of intradural hematoma and hematoma within the tumor cavity. The OP report states "We opened the fascia up and there was hematoma under the fascia that was removed. We then opened the dura and the blood clot was under pressure. Both the cuboid and clot was over the spinal cord. This was removed. There was also a clot within the tumor cavity which was irrigated and carefully removed. We then sewed in a dural graft." Thanks!

Medical Billing and Coding Forum

Laminectomy + arthrodesis help

Hello,
I am new to neurosurgery coding. I have an op note that states surgeon did a decompressive laminectomy on L4-L5 for disc herniation as well as posterolateral arthrodesis on same level. My question is…do I append the modifier 59 to decompression (63030) or is it included in fusion (22612)????
Any help would be appreciated. Thanks

Medical Billing and Coding Forum

Laminectomy with Onlay Fusion

I rarely code spinal surgeries, and am not sure if an onlay fusion qualifies for the arthrodesis code 22612.
Without giving the entire OP note, this is the Diagnosis and procedure performed.
I’m thinking 63047 for L3-4 and 22612 + ?? 63407 for fusion.

Severe spinal stenosis L3 4 L4 5 minimal spondylolisthesis L3 on 4

Operation performed:
Decompressive laminectomy, bilateral L3 4 and L4 5 with partial facetectomy
Onlay fusion L3 4

Thank you,
Cindy

Medical Billing and Coding Forum