Coding, Classification & Reimbursement

inpatient extirpation bone fragments during decompression and spinal fusion

  • 1.  inpatient extirpation bone fragments during decompression and spinal fusion

    Posted 01-12-2018 12:38
    Hello, appreciate any input on this PCS code question. I am new to this community. Patient with L3-4 disc herniation with inferiorly migrating fragment along the L4 nerve root with intractable back and leg pain. The patient had an extraction of multiple disc fragments from underneath the nerve root along the pedicle thoroughly freeing it. my question is, do we code the 01CB0ZZ extirpation of matter from lumbar nerve open approach separately in addition to the release lumbar nerve open approach 01NB0ZZ and the fusion code and the resection of the lumbar vertebral disc? It seems taking the fragments out is a separate procedure based on B3.2.c multiple procedures are coded if multiple root operations with distinct objectives are performed on same body part. One could argue both ways that the herniated disc and the bone fragments were pressing so the removing the ligamentum flavum and disc relieved the pressure (release coding only) but also fragments were removed which additionally aided the decompression (extirpation). In summary, the lumbar nerve was decompressed through removal of the ligamentum flavum and the discectomy which were pressing on it and the bone fragments were removed. Are both codes reported as listed above? of course in addition to the disectomy and the spinal fusion. Thank you. Carol

    Carol Spencer
    Inpatient Coding Educator
    University of Colorado At Denver and Health Science CTR