PROCEDURAL NOTE
PATIENT: Trohoske, Janine
AGE: 62
DATE: 01/13/2017
PREOPERATIVE DIAGNOSIS: Degenerative Disc Disease
POSTOPERATIVE DIAGNOSIS: Degenerative Disc Disease
PROCEDURE: Arthrodesis of L4-L2 utilizing autogenous bone graft
An anesthetized patient was placed in the prone position on the operating table and draped in the usual manner. An incision was made along the spinal column, from the area of the L1 to L5, and skin and subcutaneous tissues were pinned back to allow access to the L4-L2 vertebral spaces. A separate fascial incision was made to obtain morselized bone graft segments for arthrodesis procedure. Posterior arthrodesis was then performed along the L4-L2 vertebrae. No additional fixation or instrumentation was placed. Incision was then closed, stapled together, and dressed with a sterile dressing. What is the appropriate code for this procedure?
Explanation
Answer: C - The appropriate codes for this procedure are 22612 (Arthrodesis, Posterior or Posteriolateral Technique, Single Level; Lumbar) and add-on code 22614 (X2) (Additional Level of Arthrodesis). There were three levels of arthrodesis, L4, L3, and L2, so each level needs to be reported, which can be accomplished by using one 22612 and two 22614 codes. The additional code 20937 needs to be included on the claim to account for the morselized fascial bone graft performed at the same time as the primary procedure.
