Neurosurgery Coding Alert

3 case studies illustrate the unique coding requirements of laminotomy, laminectomy and excision procedures

If you're reporting multilevel spinal surgeries, such as spinal lesion excisions, laminotomies and laminectomies, you should know that CPT applies three different sets of criteria for these services.

To familiarize yourself with the requirements of each category of multilevel/segment codes and improve your coding accuracy, review the following expert-approved case studies.

The Procedure: Due to progressive spinal degeneration with sciatica, the patient requires laminotomy (hemilaminectomy) and nerve root decompression at interspaces L1/L2, L2/L3 and L3/L4.

What to Report: Code 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]) for the initial interspace (L1/L2) and two units of +63035 (... each additional interspace, cervical or lumbar [list separately in addition to code for primary procedure]) for the two additional interspaces (L2/L3, L3/L4).

Common Mistakes to Avoid: You should not append modifier -51 to add-on codes or accept fee reductions for procedures occurring at multiple spinal levels.

When reporting multilevel spinal surgeries that require "each-additional" codes, such as 63035 in the above case study, you should not append modifier -51 (Multiple procedures) to the additional codes, nor should you accept fee reductions for the additional levels, says Cathy Klein, LPN, CPC, president of Klein Consulting in Muncie, Ind. Such codes are "modifier -51 exempt," according to CPT, and the Medicare fee schedule assigns relative value units (RVUs) accordingly.

Payment example: The 2004 Medicare Physician Fee Schedule database assigns 23.04 RVUs to 63030 and 5.43 RVUs to 63035. If, as in case study #1, the surgeon performs laminotomy at three levels, compensation should equal (23.04 x 1) + (5.43 x 2), or 33.9 RVUs. Because the descriptor for the add-on code specifically states, "each additional interspace," the payer should reimburse both units of 63035 at full value.

"If I bill add-on procedures, I do not append modifier -51 because I do not want the add-on codes to be reduced," says Fran Richmond, billing coordinator at the Neurosurgery Clinic in Eugene, Ore. "I've also found that if I list the same code more than once [for example, 63035 on two separate lines], the payer will deny all but the first code as duplicates. If I use a single line and change the 'units' box [for example, '63035 x 2'], however, the payer will reimburse properly."

Other procedures that follow similar guidelines: vertebro-plasty, 22520-22534; arthrodesis, 22554-22632; complete laminectomy, 63045-63048; anterior diskectomy, 63075-63078; corpectomy, 63081-63103; excision of anterior intraspinal lesion, 63300-63308; injections, 64470-64484.

The Procedure: To correct spinal stenosis, the surgeon performs laminectomy across four spinal levels, from the fifth cervical vertebra to the first thoracic vertebra (C5-C6-C7-T1).

What to Report: Code 63015 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or diskectomy [e.g., spinal stenosis], more than two vertebral segments; cervical) only.

Common Mistakes to Avoid: You should not code "one or two" segment codes at the same time as "more than two" segment codes or assign one code each for separate spinal areas (cervical, thoracic or lumbar).

When coding procedures that use descriptors describing a range of spinal levels or segments, such as 63001 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or diskectomy [e.g., spinal stenosis], one or two vertebral segments; cervical), you should report one code only, regardless of the number of spinal segments the surgeon treats, Klein says.

Likewise, if the surgery spans more than one vertebral area (for instance, cervical and thoracic or thoracic and lumbar), you should select a single code that best describes where the surgeon performed the majority of the work, according to the North American Spine Society's Common Coding Scenarios.

Coding example: In case study #2, the surgeon treats four spinal levels encompassing two spinal areas (cervical and thoracic). You should select 63015 because this code describes laminectomy of "more than two" spinal segments. The exact number of segments doesn't matter: Under these code definitions, you would code six spinal levels the same as three spinal levels.

Although tempting, you should not report 63003 (... thoracic) in addition to 63015 to report the single thoracic level. This would constitute double-billing: Because the surgeon performed the majority of work in the cervical area, stick with 63015 only.

Other procedures that follow similar guidelines: arthrodesis 22800-22819; instrumentation 22842-22847; laminectomy 63001-63017; laminectomy 63180-63190.

The Procedure: Via laminectomy, the surgeon removes an arteriovenous malformation spanning three spinal levels, including T11, T12 and L1.

What to Report: 63251 (Laminectomy for excision or occlusion of arteriovenous malformation of spinal cord; thoracic) only.

Common Mistakes to Avoid: You should not list multiple code units to report single lesion removal or assign one code each for separate spinal areas (cervical, thoracic or lumbar).

You should claim a single code when describing excision of spinal lesions other than herniated disk, regardless of the number of spinal levels or interspaces the surgeon must access to remove the lesion.

And, these codes resemble the "range" codes described above in that you should apply one code that best describes where the surgeon performed the majority of work even if the surgeon must cross spinal areas (cervical and thoracic or thoracic and lumbar) to remove the entire lesion.

Coding example: In case study #3, the majority of work to remove the arteriovenous malformation occurs in the thoracic region. Because you should report only a single code for removal of lesion, the best choice is 63251.

Other procedures that follow similar guidelines: All procedures for excision of spinal lesion other than herniated disk, 63250-63290.