Hello, everyone. This is case-based spinal coding for the lumbar spine. I'm Mark Openlander. Let's get started. These are my disclosures, non-relevant for today. So again, we'll be coding by case illustration. This will be our first day in clinic as an attending, and we have some relatively straightforward procedures. For example, the lumbar microdiscectomy, the lumbar laminectomy, single-level lumbar fusion posterior, and single-level lumbar fusion anterior. Now, remember, for the lumbar spine, we have our ICD-10 diagnoses of radiculopathy, stenosis, and spondylolisthesis. And let's jump right into our cases. Our case illustration one is lumbar radiculopathy. Here you see we have an L5-S1 disc herniation. The story is a 42-year-old man with left gluteal pain radiating into the left heel. Sudden onset of her jumping for a rebound on his new sport court with his sons. He had decreased sensation, plantar aspect of the left foot, and absent Achilles reflex. Here's his imaging, L5-S1 disc herniation, left side, causing stenosis and compression of that nerve root. So his diagnoses are lumbar spondylosis, you can see the degenerative changes, some disc space collapse at L5-S1, and also lumbar radiculopathy at L5-S1. So lumbar radiculopathy is M54.17 for diagnosis code, and that is a documentation by site. So we have to choose which site that is, and that is here, 7, lumbosacral. Another ICD code that pertains to this patient is spondylosis with radiculopathy, that's M47.2, and what location, that's lumbosacral, L5-S1. So let's jump into the operation here. He undergoes left L5-S1 microdiscectomy with use of operating microscope. The microdiscectomy is 63030, use of operating microscope 69990. So in summary, we have lumbar radiculopathy diagnosis, M54.17, CPT code 63030 for the microdiscectomy, add-on code 69990. Case illustration number two, lumbar radiculopathy, multiple level. This is a 28-year-old flight attendant with progressively worsening left radicular leg pain for the past year, refractory to multiple types of other treatments, including epidural steroid injections, medial branch blocks, radiofrequency ablations, and sacroiliac joint injections. She says, I can no longer work like this. Here's her imaging, multilevel stenosis and disc herniations. Her diagnosis, lumbar spondylosis, L5-S1 with that disc-based collapse, but then she has lumbar radiculopathy at L4-5 and L5-S1. So again, we referenced our ICD-10, and we see lumbar radiculopathy is the M54. Now we have the location being lumbar and lumbosacral. How about spondylosis with radiculopathy? That's M47.2 with lumbosacral, that's seven, or lumbar, that's six. So this patient undergoes a left L4-5 and L5-S1 microdiscectomy with use of operating microscope. So we have 63030, and then our additional level of microdiscectomy is 63035, and the operating microscope, 69990. Now we're going to use these M54 codes because, again, that's the most complete diagnosis. And we have our lumbosacral and lumbar levels, that's M5417 and M5416. And we have our procedure, the microdiscectomy, 63030, and then the additional level, 63035, and the add-on code microscope, 69990. Case illustration number three, lumbar stenosis. This is a 72-year-old man who can no longer keep up with his wife hiking Camelback Mountain because of pain and weakness in both lower extremities with activity. He has stopped playing tennis altogether. His level of functioning has markedly declined over the last year. He's had no benefit from epidural injections. He did, in fact, have significant weight loss after he was dieting in order to treat his symptoms but without improvement. On examination, he has normal strength, normal sensation. He has some hyporeflexia, blunted patellar reflexes. Here's his imaging. We see lumbar stenosis, particularly lumbar 4-5, and he has that lumbar stenosis with neurogenic claudication. So let's document that lumbar stenosis, M48, and we need a location that's lumbar, M48.06. And is it with or without neurogenic claudication? So now we have our lumbar stenosis, M48.062. So the patient undergoes a lumbar laminectomy. This is a minimally invasive lumbar laminectomy at lumbar 4-5 with use of operating microscope at 63047 with microscope 69990. And summary for this case is lumbar stenosis with neurogenic claudication. And ICD-10 code M48.062, CPT code 63047, add-on 69990. Case illustration number four, lumbar stenosis, multiple level. This is a 66-year-old woman who presents unable to finish nine holes of golf. She has her legs turn to jelly. I was playing 18 holes a day this time last year. I cannot go on living like this. She has normal strength, normal sensation. She is hyporeflexic on examination, absent right patellar reflex. She cannot walk in Costco without leaning over the cart. She has a predominance of right radicular leg pain that goes just below the knee. And she does have lumbar stenosis on imaging. So we are obtaining our ICD-10 code for diagnosis. The lumbar stenosis, M48. And then we need a location, and that's lumbar, so .06. And we have our lumbar radiculopathy codes with M54. Location is lumbar, M54.16. So we have our lumbar stenosis code, M48. Now is it with or without neurogenic claudication? M48.062 is relevant for this patient with neurogenic claudication. Here are our ICD-10 diagnosis codes once again. Now the patient also reports intermittent loss of bladder function. We have G83.4 as a caudaquina syndrome diagnosis. So this patient undergoes lumbar laminectomy, multiple level, in this case, lumbar 3-4, lumbar 4-5, and also with use of operating microscope 63047, or the additional level, 63048, with a microscope 69990. So in summary, we have our ICD-10 diagnoses, M48.062, M54.16. Our CPT codes, this is a laminectomy, 63047, and the additional level, 63048, and then the add-on microscope code, 69990. Case illustration number five, lumbar degenerative disc disease. This is a 52-year-old woman with past surgical history, significant for an L5S1 microdiscectomy, performed 15 years prior, presenting with progressively worsening axial back pain and a mild radicular component. Three months of physical therapy without improvement, countless epidural injections, medial branch blocks, radiofrequency ablations. By examination, she has decreased sensation to the dorsum of the left foot, positive straight leg raised test. This is her imaging, L5S1, disc space collapse, spondylosis. So we have our ICD-10 diagnoses, lumbar spondylosis with L5S1 radiculopathy, M47.27, lumbosacral radiculopathy, M54.17. And we're going to choose M47.27, lumbar spondylosis with radiculopathy. It gives the most information based on the pathology. So the patient undergoes anterior lumbar interbody fusion. These are the CPT codes. So 22558 is arthrodesis anterior interbody technique, and that includes the disc space preparation, discectomy, osteophytectomy, anterior decompression of nerve roots, if performed, and the lumbar spine. In this case, we have a modifier 62 for co-surgery for the approach surgeon. Our other CPT code is 22853, biomechanical spacer, which in this case is the cage, as you see, and 20930, morselized allograft. Let's move on to case illustration six, lumbar spondylolisthesis. This is a 52-year-old woman with back pain and right radicular leg pain. She has 50% of her spine, right radicular leg pain. She has 50% back pain, 50% leg pain. Let's look at that imaging with stenosis, and in this case, as well, mobile L45 spondylolisthesis. You can see that there's a facet cyst or synovial cyst matching the site of her radiculopathy. So her ICD-10 diagnoses are spondylolisthesis, lumbar stenosis with neurogenic claudication, facet cyst, and instability. So spondylolisthesis, M43.1, and then location, lumbar, M43.16. Lumbar stenosis, M48, and what location? Lumbar, so M48.06. How about the facet cyst? Well, these fall under the M71.3 ICD-10 diagnoses, and in this case, M71.38 for other bursal cyst. Now, for spinal instability, we have the following diagnosis codes. Look at the placeholder X for future expansion, and we know that we're in the lumbar region. So here are all of our diagnoses for this patient. Spondylolisthesis, M43.16, lumbar stenosis, M48.062, facet cyst, M71.38, and instability, M53.2X6. This patient undergoes decompression with interbody fusion, T-LIF, and you can see that there is a complete decompression here in addition to the instrumentation and the interbody cage placement. So you can see the decompression here is above and beyond what would be required simply to place the cage. And here is the postoperative imaging. So how do we code this T-LIF, this transforaminal lumbar interbody fusion? That can be either 22630 or 22633, whether a posterior-lateral fusion was also performed, which would be the 22633 combined fusion. Now, we can use any specialized retractors or an endoscope, microscope, loops, headlight, but we don't report 63056, which is the transparticular decompression, or 63047, which is the laminectomy without T-LIF. So let's look at how we will code this. You can see as we move through the procedure, we are placing our screws, placing our cage, decompression is performed, and so we know what this procedure involves. Pedicle screws, decompression with laminectomy, facetectomy, interbody cage placement with interbody fusion, and then the posterior-lateral autograft and allograft. In this case, given the T-LIF with posterior-lateral fusion, we will be using 22633. That's combined posterior fusion with interbody fusion. For decompression with the T-LIF now, 63052. This was a relatively new code that came about after 63047 was unable to be reported with the T-LIF procedure. What about instrumentation? This is a non-segmental instrumentation, 22840. We have our peak implant, 22853, our bone, our allograft code, 20930, local autograft, 20936, and use of operating microscope, 69990. That's the single-level T-LIF. And that concludes this portion of the lumbar case-based coding. Thank you very much.

case-based spinal coding

lumbar spine

ICD-10 codes

CPT codes

lumbar radiculopathy