Procedural Findings & RPL Revalidation Report
Patient: MC-002 (synthetic) • Date: 2025-10-20
Procedural Findings Summary
- Two-level lumbar decompression: L4–L5 and L5–S1
- Tight neuroforamen at L5–S1 → decompressed
- Bilateral lateral recess narrowing at L4–L5
- No discectomy or anterior/posterior instrumentation
- Insertion of 2 interspinous devices (motion-preserving, non-fusion)
- Microscope use, intraoperative imaging, and general anaesthetic
RPL Codes – Revalidated
| Code | Description | Claim Justification |
|---|---|---|
| 5760 | Laminectomy, facetectomy, decompression for lateral recess + stenosis (1L) | L4–L5 decompression |
| 5761 | Laminectomy, facetectomy, decompression for lateral recess + stenosis (Add) | L5–S1 decompression |
| 2831 ×2 | Neurolysis: Major (per level) | Bilateral decompression, per level |
| 2940 ×2 | Lumbar osteophyte removal (per level) | Assumed for lateral recess clearance |
| 5770 | Use of microscope in spinal procedures | Implied by standard decompression protocol |
| 0713 | EMG (per region) | Diagnostic phase |
| 0730 ×2 | Limb SSEP (per limb) | Diagnostic; L4–S1 radiculopathy |
| 0733 ×4 | Nerve conduction study (single nerve) | Diagnostic |
| 0009 | Assistant surgeon fee | Validated earlier |
Codes You Asked About: Re-Evaluated
| Code | Description | Claim Status | Reason |
|---|---|---|---|
| 5758 | Laminectomy with decompression of nerve roots & disc removal (each level) | Not justified | No disc herniation or removal performed |
| 5755 | Laminectomy for spinal stenosis (excl. discectomy, foram., spondylolisthesis) | Overlaps with 5760/5761 | Already covered under 5760/5761 (more specific) |
| 0962 | Posterior segmental instrumentation: 2–6 vertebrae | Not applicable | No spinal fusion or pedicle instrumentation used |
| 0943 | Laminectomy + disc removal + nerve root decompression (1 level) | Not applicable | No disc removed; 5760/5761 more accurate |
Final Determination
- Keep: 5760, 5761, 2831×2, 2940×2, 5770, 0713, 0730×2, 0733×4, 0009
- Do not add: 5755, 5758, 0962, 0943
RPL Billing Guidance for Interlaminar (Interspinous) Spacers
There is no dedicated RPL code for:
- Interlaminar or interspinous spacer insertion
- These are bundled under the decompression codes used (e.g., 5760, 5761)
Therefore:
- You have already appropriately coded the procedure using 5760/5761
- Do not add fusion/instrumentation codes (0962, etc.) unless a pedicle screw-rod system was used
Procedure Summary
The patient underwent anterior cervical discectomy, decompression, neurolysis, and fusion at three levels (C3/4, C4/5, and C5/6) with disc replacement at the C5/6 level under general anesthesia via a right-sided anterior cervical approach.
- Careful exposure of cervical vertebrae C3 to C6
- Complete removal of intervertebral discs causing neural compression
- Decompression and neurolysis of nerve roots using magnification
- Preparation of vertebral endplates for optimal fusion
- Insertion of a cage packed with synthetic bone substitute to restore disc height and alignment
- Proper position and screw placement confirmed by fluoroscopy
- Wound closure in layers using absorbable sutures
Post-op plan includes collar use, assisted mobilization, wound care, and follow-up at 6 weeks with imaging.
Generated by MedCascade • Sample data for demonstration • Not medical advice