Anesthesia Coding Alert

Correctly coding for lumbar laminectomy and laminotomy is a puzzle for many coders. CPT Codes 2002 includes a range of codes that seemingly describe various surgical options, but even the most experienced coders admit that these descriptions don't always fit the operative notes. Marvel J. Hammer, RN, CPC, president of MJH Consulting in Denver, says, It is important for the coder to answer the following questions prior to selecting the correct CPT code:

The key to correct coding and billing lies in matching the CPT descriptors with the surgeon's notes and ensuring that the diagnosis supports medical necessity. ""It is essential that the coder have a clear understanding of what surgery was actually performed. This may involve assisting the physician to better document the procedures performed,"" Hammer says.

Understanding the Anatomic Terms

An accurate definition for medical terms is important to correct coding. A vertebral segment or body is one complete vertebral bone with its associated articular processes and laminae, e.g., L1, L2, L3. A vertebral interspace is the nonbony compartment between two adjacent vertebral segments and contains the intervertebral disk, e.g., L2-L3.

Laminectomy is the removal of all or part of the posterior arch (including the spinous process) of a vertebral body. Laminotomy (also referred to as hemilaminectomy) is the partial or complete removal of the bony lamina of one side of the vertebral body. Laminectomy and laminotomy can also include foraminotomy (opening or enlarging of the foramin), facetectomy (partial or complete removal of the facet), and excision of a herniated intervertebral disk. The goal of these procedures is to decompress the nerves of the spinal cord by enlarging the spinal canal.

When more conservative therapies (such as physical therapy, anti-inflammatory medication, and epidural steroid injections) do not adequately relieve the patient's symptoms, surgical intervention is often recommended. Decreased pain, weakness, and/or numbness in the legs or buttocks are the expected outcome following surgery.

According to the local medical review policies (LMRP) for Alabama Blue Shield, the state's Medicare Part B carrier, ""Laminectomy is indicated for, but not limited to, spinal stenosis (e.g., 724.02, lumbar region) as a result of spondylosis, degenerative spondylolisthesis, developmental stenosis, trauma, metabolic processes, or prior surgery."" Their LMRP lists a number of ICD-9 codes that support the medical necessity of laminectomy, including some dorsopathies (e.g., 721.0-721.42, 723.0), acquired spondy-lolisthesis (738.4), and congenital anomalies (756.11-756.12).Coders should check the LMRP for their carriers because policies vary from state to state.

In an Internet article titled ""Lumbar and Cervical Spinal Stenosis"" (http://www.spineuniverse.com/displayarticle.php/article209.html), Steven R. Garfin, MD, professor and chairman of the department of orthopaedics at the University of California, San Diego, notes that the most common surgery in the lumbar spine is decompressive laminectomy. Corresponding CPT codes for this surgery include:

Hammer says, ""For a patient with lumbar spinal stenosis, a common scenario could be a posterior lumbar two-level (L4 and L5) laminectomy. This would be coded as 63005. If the surgical notes indicate that the surgery also included a hemifacetectomy and foraminotomy, the CPT codes would change to 63047 and 63048.""

Laminotomy is another surgical option, and both laminectomy and laminotomy may include foraminotomy and medial facetectomy. ""Again, the surgical notes should indicate the extent of the procedure,"" Hammer says. Lumbar laminotomy codes include:

Hammer says that while laminotomy may be performed for spinal stenosis, another common scenario involves herniated lumbar intervertebral disks, a common cause for low back pain and leg pain. The CPT code for a lumbar single interspace (L5-S1) laminotomy with diskectomy is 63030.

Heidi Stout, CPC-CCSP, reimbursement manager for University Orthopedic Associates in New Brunswick, N.J., also offers coders this advice: ""While the code assignment is the same, there is a subtle difference in technique between laminotomy and hemilaminectomy. I believe laminotomy involves making a hole or portal in the lamina to access the intervertebral disk. Hemilaminectomy involves removal of either the right or left lamina and is often performed for lateral recess stenosis. If in doubt, check with the surgeon.""

Original Procedure Versus Re-Exploration

Another distinction in codes concerns re-explorative procedures. According to many Medicare Part B carriers, re-exploration lumbar laminotomy with decompression is generally a more extensive surgical procedure than the original laminotomy with decompression. Re-exploration may be indicated for reoccurrence of symptoms, including low back pain or failed back syndrome. CPT codes for reexploration include:

To Modify or Not to Modify

Some coders and billers say that references differ on the use of modifiers with these procedures, depending on what procedures the surgeon does or does not perform. For example, is it appropriate to append modifiers -22 (Unusual procedural services) or -52 (Reduced services) if the laminectomy (e.g., 63047) does not include foramin-otomy? And, is it ever necessary to attach modifier -50 (Bilateral procedure)? The answers, as frequently is the case, differ among carriers. ""Unfortunately, there is no consistent policy regarding when modifiers are needed for these procedures. As processing policies vary among carriers, coders and billers should contact their local Medicare carriers and private insurers to determine claim requirements,"" Hammer says.

Also keep in mind that if the surgical note includes documentation of arthrodesis or interbody fusion, some payers may bundle the laminectomy or laminotomy codes with the arthrodesis, depending on whether the purpose of the procedure was decompressive in nature or solely preparatory for the fusion.