Discectomy with a foraminotomy

How would a discectomy with a foraminotomy be coded if there is no laminectomy or laminotomy included in the procedure?


Thank you

re: Discectomy with a foraminotomy

It would be very unusual to do the procedure without removing any lamina. I find, when I audit op notes, that the surgeon just doesn't document the laminectomy/laminotomy but s/he really does it. You might want to ask the surgeon to see if s/he did remove any lamina - if so, s/he should append the operative note so you can report the correct code.

Kim Pollock, RN, MBA, CPC
KarenZupko & Associates, Inc.
www.karenzupko.com

re: Discectomy with a foraminotomy

I did query the physician and it was not performed. I should also mention this was an anterior approach.

Thanks

re: Discectomy with a foraminotomy

Well, that was an important piece of missing information. It appeared to be a posterior approach when you asked about the laminectomy/laminotomy. You don't mention the spinal region (eg, cervical, thoracic, lumbar) and the code will be dependent on this information. The anterior fusion codes (eg, 22551, 22554, 22556, 22558) include a discectomy. Or you can look at the anterior discectomy codes (63075, 63077) if no fusion was performed. It really is going to depend on what else was done and/or what the operative report says.

Kim Pollock, RN, MBA, CPC
KarenZupko & Associates, Inc.
www.karenzupko.com

re: Discectomy with a foraminotomy

I should have asked if a foraminotomy is included in a discectomy instead of my original question.
Thank you again for your assistance. You are always so helpful.