Lumbar Discectomy (Microdiscectomy)
Right [left] L[4-5 / 5-S1] disc herniation with [radiculopathy / neurogenic claudication / cauda equina syndrome], confirmed on MRI
Same
Right [left] L[X–X] microdiscectomy [/ bilateral decompression]
[***, MD/DO]
[Resident/PA name]
General endotracheal
The patient is a [age]-year-old [male / female] with right [left] [L4/L5 / L5/S1] radiculopathy refractory to [X weeks] of conservative management including physical therapy and epidural steroid injections. MRI demonstrates [posterolateral / central] disc herniation at [L4-5] compressing the [L5] traversing nerve root [/ posterolateral disc herniation at L5-S1 compressing the S1 traversing root / foraminal herniation at L4-5 compressing the exiting L4 root / foraminal herniation at L5-S1 compressing the exiting L5 root]. The risks, benefits, and alternatives were discussed and informed consent was obtained.
Intraoperatively, a [large / moderate] [posterolateral / central / foraminal] disc herniation was identified at [L4-5 / L5-S1] compressing the [L5 / S1] traversing nerve root [/ exiting L4 root at the L4-5 foramen / exiting L5 root at the L5-S1 foramen]. Following discectomy, the nerve root was decompressed and freely mobile. No epidural hematoma or instability was encountered.
The patient was positioned prone on a [Wilson frame / Jackson table] with the abdomen free. Fluoroscopy was used to confirm the operative level by needle localization prior to incision. [L4-5 / L5-S1] confirmed.
A [2–3]-cm midline incision was made centered over [L4-5 / L5-S1]. The lumbodorsal fascia was incised. The paraspinal muscles were subperiosteally elevated and retracted with a self-retaining retractor. The [L4-5 / L5-S1] interlaminar space was identified. Under loupe magnification [/ operating microscope], the ligamentum flavum was incised and removed with Kerrison rongeurs. A medial [L4 / L5] laminotomy was performed as needed.
The nerve root was identified and gently retracted medially with a nerve root retractor. The disc herniation was identified in the lateral recess / subligamentous position. The posterior longitudinal ligament was incised with a [#11 long-handled blade / angled curette]. The disc fragment was removed with pituitary rongeurs. A [3-mm] curette was used to probe the disc space: [residual loose fragments were removed / no further fragments identified]. Hemostasis was achieved with bipolar cautery and [Gelfoam / Surgicel].
Following decompression, the nerve root was freely mobile with no residual compression. The wound was irrigated. Fascial closure was performed with [0-Vicryl]. Skin was closed with [2-0 Vicryl / 3-0 Monocryl].
None
Disc material sent to pathology
[X] mL
None
The patient was taken to the PACU in stable condition. Neurological status was checked in the recovery room. Ambulation was initiated on the same day. The patient was discharged home [/ on postoperative day 1].
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Right/Left L*** disc herniation with radiculopathy
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Right/Left L*** microdiscectomy
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General endotracheal
INDICATIONS: .PTAGE-year-old .PTSEX with L*** radiculopathy, failed conservative management *** weeks. MRI: *** herniation at L***, *** root compression. Consent obtained.
FINDINGS: *** posterolateral/central disc herniation at L***, compressing *** root. Post-discectomy: root freely mobile.
PROCEDURE:
Prone on Wilson frame/Jackson table. Fluoroscopic level confirmation: L*** confirmed. *** cm midline incision. Fascia incised. Paraspinals elevated. Interlaminar space identified. Ligamentum flavum removed, Kerrison. [*** laminotomy.] Loupes/microscope. Nerve root identified, gently retracted medially. Herniation identified ***. PLL incised with #11 blade. Fragment removed with pituitary rongeurs. Disc space probed; no residual. Hemostasis bipolar/Gelfoam. Root freely mobile. Irrigated. Fascia 0-Vicryl. Skin closed.
EBL: *** mL
SPECIMENS: Disc to pathology
COMPLICATIONS: None
DISPOSITION: Neuro check PACU. Ambulated same day. DC home.
Signed: .ME, .MYDEGREE
.TODAYVariants
Cauda Equina Syndrome: Emergency Decompression
Given acute cauda equina syndrome with [saddle anesthesia / urinary retention / bowel and bladder dysfunction] beginning approximately [X] hours before surgery, emergent decompression was performed. A bilateral laminectomy was performed, and a large central disc herniation was removed. The thecal sac and nerve roots were decompressed bilaterally and were free of residual compression.
Bilateral Decompression: Over-the-Top Technique
For central stenosis with bilateral symptoms, a unilateral approach with over-the-top bilateral decompression was performed. The ipsilateral laminotomy was extended and the operating table was tilted to allow retraction of the dural sac and decompression of the contralateral lateral recess and foramen. This technique preserves the midline ligamentous structures (supraspinous, interspinous) and avoids bilateral facet removal, reducing instability risk compared to full laminectomy.
Charting Tips
- Document fluoroscopic level confirmation before incision. Wrong-level surgery is one of the most common surgical never events in spine surgery. The operative note must explicitly state that fluoroscopy confirmed the operative level before skin incision.
- Document the extent of laminotomy and facet joint preservation. Removing more than 50% of a facet joint creates instability requiring fusion. Document how much facet was removed and confirm that >50% was preserved on each side.
- Document post-decompression nerve root mobility. After discectomy, explicitly state that the nerve root was 'freely mobile without residual compression.' This confirms adequate decompression and establishes the clinical endpoint of the operation.
- Foraminal vs. posterolateral herniation root pairing: for a posterolateral (paracentral) herniation, the compressed root is the traversing (descending) root at that disc level (L4-5 disc = L5 root; L5-S1 disc = S1 root). For a far-lateral or foraminal herniation, the compressed root is the exiting root one level up (L4-5 foramen = exiting L4 root; L5-S1 foramen = exiting L5 root). Document specifically which root was decompressed and which herniation pattern was present.
- Diagnosis coding separates a disc disorder with radiculopathy from radiculopathy alone, and the lumbar levels from the lumbosacral (L5-S1) level. Document the disc level and the radicular findings, and state cauda equina syndrome when present because it is coded as an additional diagnosis.
- For cauda equina syndrome, document the time from symptom onset to decompression. Delays beyond 24 to 48 hours are associated with permanent sphincter dysfunction.
Documentation & Reimbursement Considerations
- Primary service: Report Lumbar Discectomy (Microdiscectomy) as the primary service when it is the definitive operation performed.
- Single-level lumbar laminotomy with discectomy carries 11.70 wRVU and a 90-day global period, with an add-on for each additional lumbar level (3.76 wRVU). Open and tubular/minimally invasive approaches use the same codes.
- Recurrent herniation at a previously operated level more than 90 days after the index surgery is reported with the lumbar reexploration code (18.29 wRVU, 90-day global). It is a standalone primary code, not an add-on, and is mutually exclusive with the initial discectomy code at the same level. In the cervical spine, the reexploration code likewise applies only to reoperation, and using it for a first-time cervical discectomy overstates the work by about 5 wRVU per case.
- Bilateral lumbar discectomy at the same level is reported as one line with the bilateral modifier (Medicare pays 150% of the unilateral allowable). Do not use the multiple-procedure modifier or two separate lines for bilateral work at the same level.
- When lumbar fusion is added at the same session, decompression integral to the fusion approach is bundled at the same interspace. Decompression beyond what is required for fusion access requires the distinct-procedural-service modifier (not the multiple-procedure modifier) and explicit documentation that neural decompression extended beyond the fusion exposure. The multiple-procedure modifier does not unbundle NCCI edits.
- Document preoperative MRI correlation with intraoperative findings: level confirmed by fluoroscopy before incision, nerve root identified and decompressed, disc fragment description (size, location, extruded vs. contained). These details are essential for medicolegal defense and medical necessity support.