Neurosurgery Coding Alert

Do not miss add-on codes and modifiers, if applicable.

When reporting a herniated nucleus pulposus (HNP), disk bulge, or herniation, you could be leaving money on the table if you’re not correctly reporting the spinal regions and number of interspaces. Make sure you report the complete procedure and also note the global period. Coding for these procedures is easy provided you know what to specifically look for.

Learn the Laminotomy Codes

CPT® specifies four primary and three add–on codes to describe laminotomy for the primary purpose of discectomy. When reporting excision of herniated intervertebral disc, you select from code 63020 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical) or 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar) depending upon whether the procedure was done in the cervical or lumbar region.

You would report 63030 when the essential components of this code are performed; in other words, when your surgeon does a discectomy for decompression of the nerve root(s), as well as any laminotomy or laminectomy foraminotomy along with partial facetectomy, as needed for decompression of the nerves or required as part of the surgical approach.

For a reexploration, you report codes 63040 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical) or 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar) for the cervical or lumbar regions, respectively.

Keep in mind: “The re-exploration hemilaminotomy and discectomy codes 63042-63044 are intended for re-exploration discectomy and not for ex-exploration laminectomy for stenosis,” says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison. “These codes are unilateral codes and follow in sequence the primary unilateral laminotomy for discectomy codes.”

Example: You may read that a patient developed recurrent left L5 radiculopathy from a recurrent herniated L4-5 disc after prior surgery at the same level as in the distant past. Your surgeon opens the old incision, exposes the left hemilamina, and excises the recurrent disc displacement. In this case, you report code 63042.

Note: You report one unit of code 63020 (63040 for recurrence) or 63030 (63042 for recurrence) for the excision of the herniated disc in a single interspace in the cervical or lumbar regions, respectively.

“The re-exploration discectomy codes should only be reported when the prior discectomy was performed at least 3 months earlier,” says Przybylski. “If the recurrence prompts re-exploration within the 90 day global period, the primary discectomy code should be reported with the 76 modifier.”

1. Look for Add-On Codes for Additional Interspaces

For each additional interspace where a primary discectomy was performed, either in the cervical or lumbar region, you report code +63035 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar [List separately in addition to code for primary procedure]) in addition to 63020 or 63030. “This follows the convention of posterior segmental spinal procedures, in which the adjacent level treatment is reported with the same code, regardless of spinal region,” says Przybylski.

Unlike code +63035, there are two add-on codes for reexploration procedures, one for the cervical region and second for the lumbar region. For the second exploration, you chose from codes +63043 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace [List separately in addition to code for primary procedure]), +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]). CPT® code 63043 (cervical) should accompany CPT® code 63040 only for each additional level, whereas CPT® code 63044 (lumbar) should accompany CPT® code 63042.

You can ethically maximize your payment by keeping a count for each interspace. The Medicare Physician Fee Schedule database 2014 assigns 28.82 RVUs to 63030 and 5.66 RVUs to +63035. If your surgeon performs laminotomy with discectomy at three levels, compensation should equal (28.82 x 1) + (5.66 x 2), or 40.14 RVUs. Because the descriptor for the add-on code specifically states, “each additional interspace”, you can expect the payer to reimburse both units of 63035 at full value.

Note: It is unusual for your surgeon to be doing a multilevel discectomy. Some payers may limit the number of discectomies you may report to a maximum of four. Check with your payer to confirm these guidelines. “Limits for additional levels of surgery have gradually been instituted by payers including CMS for medically unlikely circumstances,” says Przybylski.

2. Do Not Miss the Bilateral Procedures

You may append modifier 50 (Bilateral procedure) to laminotomy for discectomy procedures if the surgeon performs the procedure bilaterally, i.e. on both the left and right side of the same interspace. Because CPT® specifically describes 63030-+63044 as unilateral procedures, you should append modifier 50 if the surgeon performs the re-exploration bilaterally (that is, on both the left and right side of the same interspace). You can thus get an additional compensation if the surgeon operates on both the left and right portions of the spine at the same interspace.

3. Append Appropriate Modifiers

You may learn that your surgeon does a laminotomy at different spinal levels. Correct Coding Initiative (CCI) edits list 63042 as mutually exclusive to 63030. The edits, however, allow you to report both codes in some circumstances. If your physician performs the procedures at different levels, you can append modifier 59 (Distinct procedural service) to 63042 and report both procedures.

4. Report Both Open but Not Percutaneous Endoscopic Procedures

Codes 63020, 63030, and +63035 apply to open but not endoscopic excision of the herniated disc. For percutaneous discectomy procedures, you report 62287.

5. Do Not Separately Report Any Additional Pain Management

You may read that your surgeon did a medication wash after excision of the herniated disc. In this case, you consider the administration of the pain management as being part of the disc excision procedure. You may however check with your payer. CCI edits bundle pain management procedures with 63030.

Example: CCI prevents you from reporting 64483 (Injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; lumbar or sacral, single level) or other injection procedures with 63030. It also does not allow you to break the pairing with a modifier. Therefore, payers who follow CCI edits will consider the medication wash of the surgical wound to be part of the procedure and not separately billable.

6. Confirm the Global Period

Disc herniations may recur and your surgeon may actually be operating on the same patient for the second time. When reporting recurrent herniations, you should check if the global period applies.

Example: You may read that, for a patient who underwent left lumbar discectomy two years ago, your surgeon performs a revision laminotomy with discectomy for a recurrent herniaiton at the same level and same side. In this case, you report code 63042 as the patient is out of the 90-day global period. Otherwise, you would use 63030 and append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) or 77 (Repeat procedure or services by another physician or other qualified health care professional).