Category: Neurosurgery

TDA with ACDF
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TDA with ACDF

July 22, 2021 Question: My surgeon did an ACDF at C5-C6 and C6-C7 but also did an artificial disc (TDA) at C4-C5.  Can I bill for all three procedures? Answer: Yes, you may bill for different procedures performed at different spinal levels. You may need to append modifier 59 (distinct procedural services) to reflect the...

Non-Segmental vs Segmental Instrumentation
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Non-Segmental vs Segmental Instrumentation

July 8, 2021 Question: The provider listed one of the procedure statements as bilateral percutaneous L4-L5 segmental instrumentation placement along with the fusion and decompression procedures. In the body of the note he describes placing instrumentation on both sides for the L4-L5. We queried the provider asking for correction of listed procedure to non-segmental (22840). ...

Bilateral Sciatica
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Bilateral Sciatica

June 10, 2021 Question: What is the correct  ICD-10-CM for bilateral sciatica? My doctor tells me to use both M54.31 & M54.32 but this doesn’t seem right. Answer: There is not a diagnosis code for bilateral sciatica. You are correct to use M54.32 and M54.31 to report this condition. *This response is based on the...

Two-Level Kyphoplasty
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Two-Level Kyphoplasty

May 27, 2021 Question: When doing a T12 & L3 kyphoplasty, are the correct codes 22513 (thoracic) and 22514 (lumbar)? Answer: The correct codes are 22513 (thoracic) and +22515 (additional level) for your example. It is not accurate to report two stand-alone codes (22513 and 22514) for procedures performed at the same operative session. *This...

New E/M Guidelines: Confusion
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New E/M Guidelines: Confusion

April 15, 2021 Question: I’m still confused about the new E/M guidelines.  Do these new guidelines apply to the consultation codes? Also, I have so many more questions, can you help me? Answer: Yes and yes!  First, the new E/M guidelines do NOT apply to the office/outpatient consultation codes, 9924x. So you’ll continue to code...

Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions
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Documenting Time and Medical Decision Making in the 2021 E/M Code Revisions

April 1, 2021 Question: Under the new E/M coding revisions for office visits, should we document time AND medical decision making for every visit? Answer: According to advice from the AMA (3/24/21 webinar), you should only document one or the other to prevent potential audit confusion and risk. Document time if billing by time OR...

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