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 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).

Typically the laminotomy codes (63020-63044) are at the level of the vertebral interspace and used for decom-pression of the disk space, whereas the laminectomies (63001-63017 and 63045-63048) are at the level of the vertebral segment and are used to gain further access to deeper lateral structures as a means of decompression, Reading says.

-Surgeons typically perform a laminotomy to allow improved visibility of/access to the spinal cord and possible decompression of neural structures. The advantage of a laminotomy is that the natural support of the lamina is left in place, which increases postoperative stability,- Hammer says.

When the neurosurgeon removes a portion of the lamina above and below the disk in question, consider that a one-level procedure and use codes 63020-63035, which are reported per interspace, Phelan says.  Traditionally, neurosurgery practices have used 63030 when there is a diagnosis of herniated nucleus pulposus (HNP), disk bulge or herniation, Phelan adds.

Include the Bilateral Modifier

The laminotomy codes are inherently unilateral, so if your neurosurgeon performs the laminotomy on both the right and left side in an interspace, you should report the procedure code with modifier 50 (Bilateral procedure) appended, Reading says.

Remember: Code 63030 includes microdissection and/or laparoscopically assisted approach, so you cannot separately report these services, Phelan says. Also keep in mind that you should not code a laminectomy and laminotomy at the same level in the same operative setting, because these code are bundled by the National Correct Coding Initiative.

Even though the procedures are often done together, NCCI considers that extending the laminectomy to remove part of the adjacent lamina and enter the disk space doesn't add enough effort to justify separate billing. However, you can append modifier 59 (Distinct procedural service) if the neurosurgeon performs the laminotomy at a different level or side than the laminectomy. You can even add modifier 22 (Unusual procedural services) to 63047 at the same level/side if the physician documents sufficient additional work.

Sage advice: -I am a big fan of color coding your CPT book. Highlight laminotomy codes one color and laminectomy codes another,- Reading says. If the neurosurgeon does not clearly label in the procedure header which procedure he's performing, look in the procedure detail for terms such as -partial- or -complete/total- removal of the lamina to help you determine which code to use, Hammer says.