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Neurosurgery Coding Alert

Coding Strategy:

Swim Downstream To Full Gill Procedure Pay With These Tactics

Published on Tue Dec 04, 2012

Rule out fusion and confirm decompression.

The Gill procedure, though not commonly done, may leave you confused if you are not clear on the structures removed and the nerve roots decompressed. See the advice that follows on what's needed to clearly document services so that you'll arrive at the correct code.

Check Documentation

You report 63012 (Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar [Gill type procedure]) when your surgeon specifically reports spondylolisthesis which is the slip of one vertebral body relative to another.

An important cause of this slip is the discontinuity of the isthmus, also called the pars interarticularis, which typically occurs at L5. Fibrocartilaginous tissues develop at the pseudo-joint. This may lead to nerve root compression. A Gill procedure is done to correct compression from the spondylolisthesis. "A Gill procedure includes removal of the facets and most or all of the lamina and any other bony or soft tissue found to be compressing the spinal cord, nerve root or cauda equina. It is usually done to relieve pressure due to spondylolisthesis," says Rena Hall, CPC, Kansas City Neurosurgery, North Kansas City, Missouri. The procedure essentially consists of removal of the loose lamina and excision of the fibrocartilaginous tissue in order to decompress the nerve root. "The work of arthrodesis in not considered part of this procedure, but may be reported separately," says Gregory Przybylski, MD, director of neurosurgery, New Jersey Neuroscience Institute, JFK Medical Center, Edison.

Example: You may read that your surgeon made a midline lumbosacral incision and dissected the paravertebral muscles on both sides. Further, you may read that your surgeon removed the spondylolytic lamina, supererior articular processes and the fibrocartilaginous mass of the pseudo-joint to adequately decompress the spinal nerve roots. Your surgeon may also remove the inferior articular processes to achieve the decompression and may place a suction drain if needed before closing the wound.

Tip: Make sure your surgeon clearly documents that the condition being treated is spondylolisthesis.

Documentation of 'instability with caudal root compression' does not suffice. "This code would be used in place of another decompression code like 63047. You would not report both 63012 and 63047 at the same level," says Przybylski.

Do Not Separately Report Decompression

When reporting code 63012 for Gill procedure, you need to be careful that decompression, if any done by your surgeon, is inclusive to the procedure. You do not separately report the decompression done at the same level in the spine.

Example: You may read that your surgeon did a Gill procedure at L5-S1 and performed a wide foraminotomy of the L5-S1 roots bilaterally for decompression and facetectomies. In this case, you report 63012 for the Gill procedure. The decompression here is inclusive in 63012. Here, your surgeon is removing the spinous process of L5, the L5 lamina, and the L5 facets.

In addition, your surgeon may excise the ligamentum flavum at the L5 level and decompress the fifth lumbar nerve root, and also remove any additional bone and other structures that might be applying pressure to the nerve roots.

Tip: You report 63012 for both bilateral and unilateral decompression. You do not report two units if your surgeon performs the procedure on both sides of the spine. "CPT® 63012 is unlilateral (though not often done unilaterally) or bilateral procedure so multiple units would not be appropriate, nor would adding a bilateral modifier (50)," says Hall.

Add Diagnosis Codes

When reporting spondylolisthesis, you report diagnosis codes 738.4 (Acquired spondylolisthesis) or 756.12 (Spondylolisthesis congenital) depending upon whether the condition is acquired or congenital. Typically, the latter code is used.

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