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.

Q: A patient with lumbar stenosis and spondylolisthesis presents for a spinal fusion. The midline was decompressed up to the L4 level. Satisfied with the decompression, the surgeon performs a posterior lumbar spinal fusion at L3-L4 using local bone graft.
A: A patient with lumbar stenosis and spondylolisthesis presents for a spinal fusion. The midline was decompressed up to the L4 level. Satisfied with the decompression, the surgeon performs a posterior lumbar spinal fusion at L3-L4 using local bone graft.
Reference: AHA Coding Clinic First Quarter 2019, page 30: Spinal Fusion Performed at Same Level as Decompressive Laminectomy
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