This page addresses follow-up questions and additional information pertinent to our webinar
Spinal Decompression Procedure Coding: Taking the Pressure Off.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.
Q: When reviewing an operative report for spinal decompression, what specific language or details do you rely on to determine code choice?
A: I cannot stress this enough; we need to be working with our surgeons to include specifics on which neural elements are being decompressed. It’s nearly impossible to select the code without that information.
Q: How do you distinguish between vertebral levels and segments when assigning decompression codes?
A: Many of the codes in the spinal decompression section include the verbiage “vertebral segment,” but remember, these are neurological procedures. The segment is the bony structure that gets taken down, but what was the intent in doing so? To count the correct number of levels, we need to know which neural element is being decompressed at each segment.
Q: How do we code for a case where a patient had a herniated disc at L1 but then full decompression for stenosis at L2 and L3?
A: It’s acceptable to unbundle different types of decompression procedures when performed at separate spinal levels. In this example, it would be correct to code 63030-59 for L1, then 63047/63048 for the next two levels, depending on how many nerves were decompressed.
Looking for additional information on this topic?
Meet the Presenter: Deanna Upston, CPC, CCS, CPMA, COSC
Deanna is a Senior Coding Quality Auditor for The Haugen Consulting Group with over 20 years of health care industry experience. Her introduction was through medical assisting, which she enjoyed for several years. Once she was established at a surgeon’s office, she started coding their surgical cases and discovered that was her favorite part of the day. Deanna has experience working on the professional fee side of coding, audit, education and compliance serving coders and physicians. She has put together multiple education sessions for both provider and coder. She also has experience working as an analyst in which she validated the integrity of editing logic during the implementation of claim scrubbing software.
0 Comments