tci Part B Insider - 2010 Issue 25

Reader Questions: Multiple Procedures Across Multiple Spinal Levels

Question: During an operative session, my neurosurgeon performed the following procedures: L4-L5 diskectomy, L5-S1 diskectomy, L4-L5 transforaminal interbody fusion using posterior interbody technique, L5-S1 transforaminal interbody fusion using posterior interbody technique, bone graft placement (autograft), L4-L5 interbody cage placement, L5-S1 cage placement, and L4, L5, S1 bilateral pedicle screw instrumentation. How should I report this procedure?Alaska SubscriberAnswer: From the description you provide, your surgeon likely performed a transforaminal lumbar interbody fusion (TLIF)procedure. If the surgeon performed the L4- L5 transforaminal interbody fusion using a posterior interbody technique, you should report 22630 (Arthrodesis,posterior interbody technique, including laminectomy and/or...

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