Forum - Questions & Answers

Apr 13th, 2011 - lhardin0621

Laminotomy, Mircodiskectomy

Hello I need help I am sooo confused.

I have to procedures, both are Lamiotomy, Microdiskectomy of the Right L5-S1 and one of the left L5-S1.

The first report read as follows: With a high speed drill and series of roungeurs, laminotomy was created left L5-S1, including the medial most aspect of the facet complex. Ligamentum flavum was sharply incised taken down with a series of roungeurs. We proceeded with the operating microscope, There was a very large extruded disc herniation compressive to the thecal sac and the lest S1 nerve root. It was significantly stretching the nerve root very tight and displacing it posteiorly. Routine disckectomy was accomplished with multiple very large extruded fragment. Routine disckectomy accomplished within the disc space to make sure there were no further loose fragments and this throoughly decompressed the neural elements.

I coded this as 63030, I did not code 69990 due to NCCI edit wont allow the codes to be billed together.

The second report read as follows: With the high speed drill, laminotomy defect created inculding the medialmost aspect of the L5-S1 complex on the right,=, Ligamentum flavum was sharply incised, taken down with a series of roungeurs. We proceeded with the operating microscope. There was extruded disk fragments coming from the L5-S1 disk space that was somewhat attenuated posteriorly. Routine diskectomy was accomplished and mutiple fragments of herniated disk material that were comprimising the right S1 nerve root deviating posteriorly. A portion of this was somewhat calcific coming along the inferior endplate of L5 taken down with a high speed drill then routine diskectomoy accomplised and multiple further fragments of disk material, thoroughly decompressing neural elements.

I coded this as 63030 and 63035 due to the addtional diskectomy performed on L-5 was that correct. And is that were the second diskectomy took place in L-5?



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