# Foraminotomy stand alone procedure



## julyagroves (Oct 28, 2016)

I am having trouble deciding how to code a foraminotomy as a procedure WITHOUT the laminectomy performed for decompression.  
I am torn between coding as a 63045-53 and a 64999
Any feedback would be helpful.
Thank you
-July


PREOPERATIVE DIAGNOSIS
1. Cervical foraminal stenosis C6-7.
2. Cervicothoracic foraminal stenosis C7-T1, left.
3. Left upper extremity radiculopathy.

POSTOPERATIVE DIAGNOSIS
1. Cervical foraminal stenosis C6-7.
2. Cervicothoracic foraminal stenosis C7-T1, left.
3. Left upper extremity radiculopathy.

PROCEDURE PERFORMED
1. Left C6-7 foraminotomy.
2. Left C7-T1 foraminotomy.

ANESTHESIA
General endotracheal.

ESTIMATED BLOOD LOSS
Less than 30 mL.

INDICATIONS
Patient is a XX-year-old male with intractable left upper extremity pain.
Imaging has shown significant foraminal stenosis at C6-7, C7-T1 concordants
with patient's clinical symptoms. After discussion of indications, risks,
benefits, and expected outcome of continued nonoperative versus operative
treatment, the patient has elected to proceed with surgical decompression.
Understanding and accepting of the inherent risks and limitations to this
operation, including the potential need for further surgery, patient gives
verbal and written consent.

OPERATIVE DESCRIPTION
After a positive ID was made, the patient was brought to the operating suite
and general endotracheal anesthetic was administered without complication.
The patient was positioned prone on the operating room table with chin tucked
and cervical spine flexed. Arms were taped and tucked at the sides. The
patient was placed in reverse Trendelenburg position and the posterior neck
was prepped and draped in the usual sterile fashion. Mr. XX did receive
preoperative IV antibiotics and perioperative mechanical deep vein thrombosis
prophylaxis. C-arm fluoroscopy was brought in and identified the underlying
spinal landmarks to position a midline incision overlying the posterior
elements of C6 to T1. Soft tissues were anesthetized with local anesthetic.
The skin was sharply incised in the midline and carried down through the
dermis, subcutaneous tissues to the fascial layer, which was again divided
midline. Using careful dissection off the C7 and T1, the paraspinal
musculature was dissected free from the left hand side of the lamina of C6,
C7, and T1 out to the facet joints at C6-7 and T1. Self-retaining retractors
were placed, C-arm fluoroscopy again confirmed approach levels. Using a
cervical bur, curettes, and Kerrison rongeurs, foraminotomies at C6-7 and
C7-T1 were performed decompressing the existing roots. After decompression
was completed, a micro ball probe was utilized to confirm absence of
obstruction through the foramen. The wound was then thoroughly irrigated,
hemostasis was visually confirmed, and then the wound was closed in a layer
fashion with a final running subcuticular stitch, reinforced with
Steri-Strips. Sterile dressings were placed. Sponge, needle, and
instrument counts were reported correct at the end of the case by the
hospital staff. Patient was returned to the supine position, awakened from
general anesthetic, and extubated without complications. Intraoperative
neuromonitoring was flat throughout and will be summarized under a separate
note. Patient was taken to the recovery room in stable condition.


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## megstone (Dec 22, 2016)

I have this also and was leaning towards 64999, is that what you're using then?


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## julyagroves (Apr 27, 2017)

*Reply from NASS*

We submitted this question and the  NASS coding Committee recommended that we code a 63045 and 63048 because two nerve roots were decompressed.


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## adwilmar (Oct 2, 2020)

julyagroves said:


> *Reply from NASS*
> 
> We submitted this question and the  NASS coding Committee recommended that we code a 63045 and 63048 because two nerve roots were decompressed.


Re-viving this thread.  Do you happen to have the explanation NASS gave you?  I ask because my Doc went in an performed a dural leak repair and once in there he performed a foraminotomy w/o mention of a laminectomy.  I don't know whether to code 63707-22 or 63709??


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