Neurology & Pain Management Coding Alert

Do you know the 3 types of decompression your provider’s likely to perform?

There are a lot of spinal surgeries your practice just isn’t set up for; many procedures on a patient’s spine are performed by orthopedic surgeons, general surgeons, or neurosurgeons.

There is a small section of surgeries that your provider might perform to address a patient’s spinal issue, however.

Check out this list of procedures your provider might perform on a patient’s spine, as well as a clinical example to give you more practical insight into this matter.

Decompression Splits Into 3 Separate Services

The most common spinal procedure most practices will see is a decompression. When looking at encounter notes, they “should indicate that the provider is decompressing a nerve or spinal cord,” Anderanin reminds coders. If this is reflected in the notes, you’ve likely got a decompression claim on your hands.

Decompression procedures your practice might perform for include:

Laminectomy: 63001 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical) through 63017 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar); 63045 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical) through +63048 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)).

During a laminectomy, “the surgeon removes the spinous process (the bony projection on the back of the vertebrae) and one or both lamina (the broad plates of bone on either side of the spinous process that complete the “arch” of the vertebrae and enclose the spinal cord), followed by decompression of the nerves. The focus of the work is the individual vertebra and the nerve roots emanating through the foramen (passageways) on either side of the vertebra. The surgeon may perform a laminectomy on several adjacent vertebral levels depending on the condition of the patient,” according to Codify.

Laminotomy: 63020 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical) through +63044 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure)).

A laminotomy, also known as hemilaminectomy or a partial laminectomy “involves removing the upper and lower portions of adjacent laminae (that is, the laminae on either side of a vertebral interspace), rather than removing the entire lamina(ae) of a single vertebra. In this procedure, the surgeon removes upper and lower portions of the laminae surrounding two adjacent vertebral interspaces. If the surgeon performs two hemilaminectomies at adjacent levels, they may choose to remove the entire lamina. Although this may look like a complete laminectomy, the procedure qualifies as two hemilaminectomies as long as the surgeon excises the intervertebral discs as well,” according to Codify.

Remember that laminectomies involve a minimum of 50 percent of the lamina, and are often performed to treat stenosis patients. Conversely, laminotomies involve less than 50 percent of the lamina and are performed to treat disc disorders.

Laminoplasty: 63050 (Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments) and 63051 (Laminoplasty, cervical, with decompression of the spinal cord, 2 or more vertebral segments; with reconstruction of the posterior bony elements (including the application of bridging bone graft and non-segmental fixation devices [eg, wire, suture, mini-plates], when performed)).

During a laminoplasty, “Under anesthesia, the physician makes an incision into the skin of the back of the neck. A groove created in one side of the cervical vertebrae. The other side of the vertebrae is then cut all the way through. Then the physician removes the tips of the vertebrae. After that, the back of each vertebrae is opened which takes pressure off of the spinal cord and nerve root. Finally, small wedges are created from bone that is placed in the open space,” according to Codify.

Look for Separate E/M Opportunity

There’s a good chance that your provider would perform a significant, separately identifiable evaluation and management (E/M) service prior to a laminectomy, laminotomy, or laminoplasty — particularly if it is a new patient, as the provider would have absolutely no first-hand information to go on before scheduling the procedure. Most preoperative E/Ms for patients about to undergo one of these procedures would be office/outpatient, which you’d code with 99201 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making …) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity …), depending on encounter specifics.

Before you can think about adding an E/M to one of these claims, however, you need to be able to show in the notes that the provider performed a history, examination, and medical decision making (MDM) that is separate from the normal preop work that would be bundled into a laminectomy, laminotomy, or laminoplasty procedure code.

Modifier alert: The codes discussed in this article all have major global surgical periods (90 days), meaning that you would append modifier 57 (Decision for Surgery) to any E/M code that accompanies your laminectomy, laminotomy, or laminoplasty procedure code. If you were reporting a separate E/M from a procedure with a minor (0- or 10-day) global period, you’d append modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) to the E/M rather than 57. If you have any doubt as to a code’s global period, check before appending a modifier and filing the claim.

Check Out This Laminotomy Example

To illustrate her point on anatomy, Anderanin ran the group through some clinical examples to show how to count vertebral segments and interspaces. Here is one of those examples, which involves a laminotomy:

Pt has herniated disc L5-S1. Placed pt in prone position, made incision to access spine. Fluoro used to confirm surgical level. Used knife to incise disc, freeing the S1 exiting left nerve root and performing microdiscectomy.

For this encounter, you’d report 63030 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar). The surgeon treated a single interspace during this laminotomy: L5-S1.