AHA Coding Clinic® for HCPCS - 2023 Issue 1; Ask the Editor

Laminectomy with soft tissue decompression

The patient, whom had a previous L4-S1 fusion and an auto-fusion of T12-L1, has now developed spinal stenosis of L1-L4 and presented for decompression. After a posterior midline incision was made to gain access, soft tissue was dissected to fully expose the L1-L3 levels. The spinous process and part of the lamina were removed from L3. The drill was then used to perform a laminectomy of the inferior aspect of L3. This was carried down to the ligamentum flavum with exposure of the epidural space.The Kerrison punch was used to remove the ligamentum flavum over the L3-4 level. Once the ligamentum flavum was removed and dissection carried down to the lateral recess of L3-4, the hypertrophied ligamentum flavum was decompressed along the lateral recess bilaterally at L3-L4.The rongeur was used to remove the spinous process of the inferior aspect of L1 and the superior aspect of L2. The inline drill was used to drill down the lamina of L1 down to the ligamentum flavum, cranially. The inferior aspect of the L2 lamina was removed using the same method. Dissection was carried out along the epidural space using a probe and the hypertrophied ligamentum flavum over the L1-L2 level was removed using a Kerrison punch. This dissection was then carried down into the lateral recess bilaterally over L1-L2. Further decompression was carried out along the lateral recess at L1-L2 bilaterally. Palpation via probe failed to identify any additional stenosis. The wound was infiltrated with a combination of anesthetic and bupivacaine liposome suspension. According to CPT Assistant, December 2021, page 10, spinal decompression can involve removal of any elements causing pressure on neural elements including soft tissue. In this case, the hypertrophied ligamentum flavum, a soft tissue, was removed from level L3-L4 for decompression without removal of bone at L4; how would this be reported? ...

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