As part of the new coding format for our newsletter, Welter Healthcare Partners is excited to offer you a new surgery coding series in which we want to help you! The 2nd week of every month we will highlight a complicated surgical case. This week we are highlighting a general surgery case. We want to hear from you! If you have a complicated surgery case and need help with coding, please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. Click Here To Submit Redacted Surgery Case Study. Click Here To Submit Redacted Surgery Case StudynnPreoperative Diagnoses:n
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- Lumbar degenerative deformity
- Lumbar spinal stenosis
- Low back pain
- Lumbar radiculopathy
- Lumbar multilevel degenerative disk disease
- Multilevel lumbar facet arthrosis
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nPostoperative Diagnoses:n
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- Lumbar degenerative deformity
- Low back pain
- Lumbar radiculopathy
- Lumbar multilevel degenerative disk disease
- Multilevel lumbar facet arthrosis
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nCorrect CPT and ICD-10 Codes with modifiers and units:nn22612 – Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed)n22614 x 2 – Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segmentn63042 – XS, RT – Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbarn63012 – 59 – Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)n63047 – Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbarn63048 – Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbarn63030 – XS, LT – Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbarn22842 – Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segmentsn61783 – 26, 59- Stereotactic computer-assisted (navigational) procedure; spinaln20931 – Allograft, structural, for spine surgery onlyn20930 – Allograft, morselized, or placement of osteopromotive material, for spine surgery onlynnM48.07 – Spinal stenosis, lumbosacral regionnM47.27 – Other spondylosis with radiculopathy, lumbosacral regionnM51.37 – Other intervertebral disc degeneration, lumbosacral region