Cracking the Code
Laminectomy Decompression with Spinal Fusion
For spinal procedures, a surgeon may complete a laminectomy (decompression) at the same level of a spinal fusion during the same encounter. This occurs for two reasons: 1) to reach the site of the spinal fusion, or 2) there is a distinct objective. This is where a coder’s critical thinking ability comes into play. Coders must thoroughly review the provider’s documentation to understand the intent of the laminectomy decompression procedure. If the provider only completes the decompression to reach the site of the spinal fusion, then it is inaccurate to report a separate code for the decompression because it is considered inclusive to the fusion. However, if the provider completes the decompression for a distinct, surgical objective, then it is accurate to capture the decompression separately. It is imperative that coders are capturing ALL components of the operative note to ensure all the appropriate procedure codes are reported for proper reimbursement.