Neurosurgery Coding Alert

Caution:  Avoid reporting both procedures at the same level

CPT has separate codes for laminectomy and laminotomy procedures, but the similarities in the procedures and the terminology can make your job challenging. Follow these expert tips to ensure you-re choosing the right surgery code every time. Gravitate to Laminectomy Codes for Complete Removal A laminectomy is traditionally the removal of the entire lamina from a vertebral segment, says Nancy L. Reading RN, BS, CPC, of Cedar Edge Medical Coding and Reimbursement in Centerfield, Utah. Neurosurgeons often perform laminectomies to treat spinal stenosis, says Marvel J. Hammer, RN, CPC, CHCO, owner of MJH Consulting, a healthcare reimbursement consulting firm in Denver. The surgery relieves pressure on the spinal cord by removing the lamina of the vertebra to widen the spinal canal and create more space for the spinal nerves.

Tip: When the neurosurgeon performs a laminectomy simply to relieve compression of the spinal cord without nerve decompression, report codes 63001-63017 as appropriate, depending on the number and location of levels.

When your neurosurgeon performs a laminectomy with nerve or facet joint decompression (i.e., at the lateral recess where the nerve exits the spinal column), the coding depends on the location of the affected vertebra(e). You-ll choose from the following codes for this type of procedure:

- 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. As the code descriptors indicate, these procedures may be unilateral or bilateral. Therefore, you-ll use the same code, with no modifiers appended, whether the surgeon removes the left, right or both laminae of a particular vertebra. If the neurosurgeon removes a lamina from more than one vertebra, report each additional level using +63048 (... each additional segment, cervical, thoracic, or lumbar [list separately in addition to code for primary procedure]).

Best bet: Work with your surgeon to get accurate, complete documentation. -The operative report should clarify the post-op diagnosis, and the wording should indicate clearly the lamina removed, whether any facets were removed, and if the foramen was widened,- says Katherine Phelan, CPC, coding and billing consultant in Tulsa, Okla. -The surgeon should specify what was done at each vertebral segment so that coder can identify the appropriate levels to code.- Choose Laminotomy Codes for Partial Removal When your physician documents an opening in the lamina at any point, you should turn to your laminotomy codes. CPT offers 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 [...]