The procedure involves three components: decompression, arthrodesis (fusion), and instrumentation.

1. Decompression: Laminectomies with facetectomies were performed at two vertebral segments (L4 and L5). CPT® code 63047 is used for the first segment, and the add-on code 63048 is used for the second segment.

2. Arthrodesis: A posterior arthrodesis was performed from L1 to L5. This spans five vertebrae and four interspaces/levels. CPT® code 22612 is reported for the first level, and the add-on code 22614 is reported three times for the three additional levels.

3. Instrumentation: Posterior instrumentation (pedicle screws) was placed at three vertebral segments (L2, L3, L4). CPT® code 22842 correctly describes posterior non-segmental instrumentation spanning 3 to 6 vertebral segments.

A. 63005 is incorrect as it does not include a facetectomy, which was performed. 63047 is the more specific code for laminectomy with facetectomy.

B. 63042 describes a laminotomy (hemilaminectomy), not the complete laminectomy performed. 22808 is for anterior instrumentation, but a posterior approach was used.

D. 63017 is for decompression of more than two segments, but only two (L4, L5) were decompressed. 22808 is for anterior, not posterior, instrumentation.

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1. American Medical Association. (2023). CPT® 2024 Professional Edition.

Code 63047: "Laminectomy

facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord

cauda equina and/or nerve root[s]

[eg

spinal stenosis])

single vertebral segment; lumbar." (p. 478).

Code 63048: "…each additional segment

cervical

thoracic

or lumbar (List separately in addition to code for primary procedure)." (p. 478).

Code 22612: "Arthrodesis

posterior or posterolateral technique

single level; lumbar..." (p. 189).

Code 22614: "...each additional vertebral segment (List separately in addition to code for primary procedure)." (p. 189).

Code 22842: "Posterior non-segmental instrumentation (eg

Harrington rod technique)

pedicle screw

facet screw

wiring; 3 to 6 vertebral segments." (p. 196).

2. AAPC. (2023). 2024 CPC® Study Guide. Chapter 8: Musculoskeletal System Surgery.

The section on "Spine (Vertebral Column)" explains the necessity of coding for each component of a spinal procedure (decompression

arthrodesis

instrumentation) and the correct application of primary and add-on codes based on the number of segments or levels involved. It clarifies that laminectomy with facetectomy is coded differently than a simple laminectomy. (pp. 245-251).