Neurosurgery Coding Alert

Make sure you're not confusing spinal segments with interspaces

To code correctly for laminectomy and hemilaminectomy (laminotomy), you must know whether the surgeon removes one or more complete lamina from a single vertebra or if he partially removes the lamina from two adjacent vertebrae.

Report Laminectomy per Segment

When choosing laminectomy codes, you should report the procedure per spinal segment, says Eric Sandhusen, CHC, CPC, director of billing and fiscal compliance for Columbia University Department of Surgery. CPT provides three primary codes and one add-on code to describe laminectomy with decompression:

• 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
• 63047 - ... lumbar
• +63048 - ... each additional segment, cervical, thoracic, or lumbar (list separately in addition to code for primary procedure).

During 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 nerves says Kee D. Kim MD associate professor of neurosurgery at University of California Davis in Sacramento. 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 laminectomy on several adjacent vertebral levels. Don't Apply Modifiers for Bilateral Laminectomy

You should report 63045 63046 or 63047 as appropriate for the first spinal level the surgeon treats followed by 63048 for each additional level beyond the first.   In addition note that codes 63045-63048 are unilateral or bilateral. Therefore you should report the same code with no modifiers appended whether the surgeon removes one or both lamina of a particular vertebra Sandhusen says.   Example: To provide spinal cord and nerve decompression the surgeon removes the spinous process and left lamina of the third cervical vertebra (C3) as well as the spinous process and left and right laminae of the fourth cervical vertebra (C4). This would be called a C3-C4 laminectomy.   In this case you should report 63045 for the first spinal level (C3) the surgeon treats followed by 63048 for the subsequent spinal level (C4).   Even though the surgeon removes only a single lamina from C3 and both laminae from C4 you report each code "as is " with no modifiers appended.   Laminectomy w/o Decompression? Look Elsewhere

If the surgeon performs laminectomy to relieve compression of the spinal cord or remove abnormal facets without nerve decompression you should choose from codes 63001-63017 rather than 63045-63048. Look to future editions of Neurosurgery Coding Alert for more information on procedures 63001-63017.   Select Laminotomy Codes per Interspace

When reporting laminotomy also known as hemilaminectomy or partial laminectomy you must describe the procedure per spinal interspace. In this case the area between the vertebrae (the intervertebral disk and surrounding area) - rather than the vertebrae themselves - is the "focus" of the surgery. Specifically laminotomy involves removal of the upper and lower portions of adjacent laminae (that is the laminae on either side of a vertebral interspace) rather than the removal of the entire lamina(ae) of a single vertebra as described by laminectomy Kim says. CPT contains four primary and three add-on codes to describe laminotomy:

• 63020 - Laminotomy (hemilaminectomy) with decompression of nerve root(s) including partial facetectomy foraminotomy and/or excision of herniated intervertebral disk; one interspace cervical
• 63030 - ... one interspace lumbar (including open or endoscopically assisted approach)
• +63035 - ... each additional interspace cervical or lumbar (list separately in addition to code for primary procedure)
• 63040 - Laminotomy (hemilaminectomy) with decompression of nerve root(s) including partial facetectomy foraminotomy and/or excision of herniated intervertebral disk re-exploration single interspace; cervical
• 63042 - ... lumbar
• +63043 - ... each additional cervical interspace (list separately in addition to code for primary procedure)
• +63044 - ... each additional lumbar interspace (list separately in addition to code for primary procedure).

Report an initial laminotomy using 63020 (cervical) or 63030 (lumbar) with +63035 for each additional cervical or thoracic level the surgeon treats beyond the first.   Report re-exploration using 63040 (cervical) or 63042 (lumbar). Code 63043 (cervical) should accompany 63040 only for each additional level while 63044 (lumbar) should accompany 63042.

Turn to Modifier -50 for Bilateral Laminotomy

Unlike 63045-63048 you may append modifier -50 (Bilateral procedure) to laminotomy procedures if the surgeon performs the procedure bilaterally.   CPT specifically identifies 63020-63044 as unilateral and therefore allows for additional compensation if the surgeon operates on both the left and right portions of the spine at the same interspace Sandhusen says.   Example: The surgeon removes the lower portion of the right and left laminae at C3 the upper portions of the right and left laminae and lower portion of the right lamina at C4 and the upper-right portion of lamina at C5 during an initial exploration. This is called a C3/C4 C4/C5 laminotomy or hemilaminectomy (see illustration at left below).   In this case you should report 63020-50 (for the bilateral laminotomy of adjacent segments C3 and C4) and 63035 (for unilateral laminotomy at the additional interspace C4/C5).