Question: Our orthopedic surgeon turned in a note that says, “Performed a bilateral hemilaminectomy with discectomy and foraminotomy for nerve decompression.Then I did a lumbar decompression with posterior lumbar interbody fusion and posterior lateral transverse fusion with pedicular screws.”
How should I report this? Is the hemilaminectomy bundled with the fusion?
Answer: No, you shouldn’t consider the hemilaminectomy with decompression part of the fusion (although more payers are beginning to bundle these procedures).
To report both, your physician must document he decompressed the spinal cord and/or nerve roots Report 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-assisted approaches; 1 interspace, lumbar) for this part of the surgery. Be sure to append modifier 50 (Bilateral procedure) to indicate that the hemilaminectomy was bilateral.
Next, report the posterior lumbar interbody fusion (PLIF), in which the vertebral endplates are separated and graft material inserted between them, using 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace [other than for decompression], single interspace; lumbar).
Report the posterior lateral transverse fusion using 22612 (Arthrodesis, posterior or posterolateral technique, single level; lumbar [with or without lateral transverse technique]). Attach modifier 51 (Multiple procedures) to 22612 since your physician performed both the PLIF and posterior lateral transverse fusion.
Note: You need to report the instrumentation as well. If the orthopedic surgeon performed a single-level instrumentation (i.e., two adjacent vertebrae), you should assign +22840 (Posterior non-segmental instrumentation [e.g., Harrington rod technique, pedicle fixation across one interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation] [List separately in addition to code for primary procedure]).
If he performed a two-level (i.e., three-segment) instrumentation attached at L4, L5, and S1, use +22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and subliminal wires]; 3 to 6 vertebral segments [List separately in addition to code for primary procedure]).
If he placed the pedicle screws and attached the instrumentation at only two places, 22840 would be correct regardless of how many levels are between the endpoints.
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