tci Medicare Compliance & Reimbursement - 2010 Issue 15

Reader Questions: Assess Multiple Procedures Across Multiple Spinal Levels

Question: During an operative session, my neurosurgeon performed the following procedures: L4"L5 diskectomy, L5"S1 diskectomy, L4"L5 transforaminal interbody fusion using posterior interbody technique, L5"S1 transforaminal interbody fusion using posterior interbody technique, bone graft placement (autograft), L4"L5 interbody cage placement, L5"S1 cage placement, and L4, L5, S1 bilateral pedicle screw instrumentation. How should I report this procedure?Answer: From the description you provide, your surgeon likely performed a transforaminal lumbar interbody fusion (TLIF) procedure. If the surgeon performed the L4"L5 transforaminal interbody fusion using a posterior interbody technique, you should report 22630 (Arthrodesis, posterior interbody technique, including laminectomy and/or diskectomy...

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