Question

LOCATION: Inpatient, Hospital

PATIENT: Karla Stevens

SURGEON: John Hodgson, M.D.

PREOPERATIVE DIAGNOSES:
1. Spinal stenosis, without neurogenic claudication.
2. Spondylolisthesis, L4-L5.
3. Right radicular pain L5 root.

INDICATIONS: Karla is a 52-year-old woman who is a baker and stands on her feet for many hours a day. She was diagnosed with spinal stenosis and spondylolisthesis and continues to have low back pain. She understands the risks and potential complications and problems that may occur from the surgery and wishes to proceed at this time.

POSTOPERATIVE DIAGNOSIS:
1. Hypertrophic ligamentum flavum.
2. Spinal stenosis.
3. Encroachment on L5 root with spondylolisthesis at L4-L5 on the right.

PROCEDURE(S) PERFORMED:
1. Laminectomy of L5 and part of L4.
2. Decompression of L5 root.
3. Inspection of disk.

PROCEDURE: Under general anesthesia, the patient was placed in prone position. The back was prepped and draped in usual manner. An incision was made in the skin and extended through subcutaneous tissue. Lumbodorsal fascia divided. The erector spinae muscles are bluntly dissected from the lamina of L4-L5 and the interspace is localized via x-ray. What I did is I performed a hemilaminectomy of L5 and part of L4 and a hemifacetectomy at L4-L5.

FINDINGS: The ligamentum flavum was hard. It was hypertrophic. There was lateral recess encroachment. The nerve root L5 was full and reddened. The disk space was not protruding, but with a little spondylolisthesis, there was some softening, but there was no extrusion of any disk material. After inspecting this, having done the decompression, the laminotomy, the foraminotomy, I decided not to enter the disk space, but the decompression would be adequate, thinking that the hard ligamentum flavum was responsible for most of this radicular pain. We will see what happens. The nerve root having been decompressed. Visually I saw that this was the nerve root that was affected. I was satisfied that we should stop there. I then put a Hemovac drain in the wound and closed the wound in layers, utilizing double knotted #0 chromic on the lumbodorsal fascia, with #0 Vicryl, 2-0 plain in the subcutaneous tissue, and surgical staples on the skin. A dressing was applied. The patient was discharged to the recovery room.

What are the CPT, ICD-10-CM, and HCPCS codes?

Answer 1

Preoperative and poatoperative diagnosis ICD 10 CM CODE FOR

1)SPINAL STENOSIS IS M48.07

2)SPONdilolethesis is M43.16

3)FOR HYPERTROPIC LIGAMENTUM FLAVUM IS M24.20

4)FOR ENCOARMENT ON L5 ROOT WITH SPONDILOLETHESIS IS SAME AS SPONDILOLETHESIS

5)RIGHT REDICULAR L5 ROOT IS M54.16

CPT CODE FOR

FOR 1 - 63030

FOR 2 - 63047 or even 63012

FOR 3 - 63047

FOR 4 - same as 2

HCPCS CODE FOR

FOR laminectomy L5 and part of L4 is 63047 and 63048

FOR decompression of L5 ROOT IS 63047

Inspection of disk is 63030.