Neurosurgery Coding Alert

Reducing claim denials and payment delays for laminectomies and laminotomies often comes down to educating the carrier about the differences between these procedures, and why it may be necessary to perform them at the same time. Changes made in CPT 2001 to the laminectomy and laminotomy codes will make this task easier for neurosurgery coders. Gaining a full understanding of these changes along with the clinical nature of the two procedures and the appropriate modifiers to accompany the codes should give neurosurgery coders the advantage necessary to ensure speedy reimbursement for these claims.

Clinical Knowledge is Essential to Successful Claims

Surgeries like this are often performed to relieve compression of the spinal cord caused by a bone displaced in an injury or accident or degeneration of a disc. To access the spinal cord, a portion of the vertebrae near the affected area may need to be removed.

The small bony arch that is either partially chipped away or completely removed is called the lamina or laminae. A laminotomy is the excision of the upper and lower portions of the adjacent laminae (e.g., at the vertebral interspace). A laminectomy is the removal of the entire lamina from a single vertebral segment. Sometimes a neurosurgeon needs to remove part of the lamina above or below the excised level to gain full access to the nerve roots and disk. Fusion is occasionally needed.

When coding for a laminotomy or a hemilaminectomy use 63020 (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, cervical) or 63030 (... one interspace, lumbar [including open or endoscopically assisted approach]) depending on the surgical site.

When doing this procedure bilaterally, use the same code and apply modifier -50 (bilateral procedure), says Richard D. Bucholz, MD, professor and associate director of the division of neurosurgery at St. Louis University in Missouri. Medicare and nearly all commercial insurance companies accept modifier -50 and pay more for the procedure when done on both sides, increasing the fee by 50 percent. This is also true for laminotomies at additional levels (+63035, laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; each additional interspace, cervical or lumbar [list separately in addition to code for primary procedure]), which can also be used with modifier -50 when done bilaterally.

Coding for Laminotomy

CPT 2001 has revised the codes for a re-exploration of a laminotomy. Codes 63040 (laminotomy [hemilaminec-tomy],with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated interveterbral disk, re-exploration, single interspace; cervical) and 63042 (... lumbar) now apply to a single interspace. This change was required by the introduction of two new add-on codes, +63043 (... each additional cervical interspace), which should be used in conjunction with 63040, and +63044 (... each additional lumbar interspace), which should be used in conjunction with 63042.

Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, a coder who specializes in neurosurgical procedures, recommends that coders note 63040-63044 are unilateral procedures and should be listed with modifier -50 when performed on both sides.

Correct Coding for a Laminectomy

Depending on the surgical site, a nonexploratory laminectomy is coded as 63045 (laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; cervical), 63046 (... thoracic) or 63047 (... lumbar). In the laminectomy procedure, the spinous process and one or both lamina are removed completely. Bucholz explains that these procedures require the same code, with no modifier -50, whether they are unilateral or bilateral.

If a bilateral or unilateral cervical laminectomy is extended above or below the segment to remove a part of an adjacent segment to perform a diskectomy, this is normally not included in the laminectomy code. In these instances, modifier -22 (unusual procedural services) is appropriate. Appending modifier -22 is a request for additional reimbursement for a more extensive procedure.

Use modifier -22 only when the surgeon documents what part of the procedure was more complicated and why. Do not append it routinely to the laminectomy code unless extra work is evident in the operative note. Modifier -22 may send up red flags to the carrier, particularly if a practice uses it often. When using this modifier, coders should increase the charge for the surgery accordingly. Submit claims about 20 percent higher when the documentation is there to justify the increase. Bucholz cautions that some carriers may view the extended laminectomy as part of the normal procedure, even though it is not specified in the code definition. But I would append modifier -22 regardless and see what kind of reimbursement they come back with, he adds.

Surgery at Multiple Levels

When coding for laminectomies and laminotomies that take place at more than one spinal segment, coders should beware of overcoding. Rather than billing for two laminectomies at adjacent levels, for instance, the appropriate method is to code for a laminectomy first, then use the add-on for the additional level(s). So, if the L4-L5 lamina are removed completely (including the spinous processes), use 63047 and 63048 (...each additional segment, cervical, thoracic, or lumbar [list separately in addition to code for a primary procedure]). If the excision is done only at the interspace between the segments, use 63030 (with modifier -50 if bilateral). If all of one level (e.g., L4) and part of the other (e.g., upper part of L5) are removed, then 63047-22 should be billed.

In all cases, when billing for laminectomies and laminotomies, the coder should include a detailed operative report that explains the patients condition prior to and during surgery and why the surgery was warranted. Neurosurgical coders who understand the differences between the two surgeries are more attuned to what documentation is required from the surgeon and can better
explain the procedures and their necessity to the carrier.