Answer: The procedure removes adhesions (tags) from the dura to correct any neurological deficits. Physicians often remove a specimen to send for lab review, but that service is included in the primary procedure.
In this situation, you’ll report 63200 (Laminectomy, with release of tethered spinal cord, lumbar) for the cord release and +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) for the microscope use. Don’t report the dural tag removal separately, as it is incidental to the tethered cord release.
Audio Training Event: Spinal Surgery Coding Secrets, with Dr. Greg Przybylski.
- Free updates on CPT, ICD-9, HCPCS, Medicare, NCCI edits, and ICD-10.
- Discounts on 3rd party offers