Neurosurgery Coding Alert

These -occasional- modifiers let you report both procedures at the same level.

You can stop struggling to differentiate 63001-63017 from 63020-+63044 if you equate "partial" with laminotomy and "complete/total" with laminectomy. Similarities in laminectomy and laminotomy procedures, and terminology, can make your job challenging. These expert tips will help you zoom in on the differences.

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 and/or nerve roots by removing the lamina of the vertebra to widen the spinal canal and create more space for the spinal cord and nerves.

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

Robert Komanetsky, CPC, physician coder at Olive Surgical Group in St. Louis.
When your neurosurgeon performs a laminectomy with nerve decompression by facetectomy (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 or right vertebra, or both vertebra's laminae. 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, Komanetsky says. The surgeon should specify what was done at each vertebral segment so the coder can identify the appropriate levels to report.

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, including open and endoscopically-assisted approaches; 1 interspace, cervical

- 63030 -- ... one interspace, lumbar

- +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, reexploration, 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 decompression 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 for decompression.

"Surgeons typically perform a laminotomy to allow improved visibility of/access to the lateral spinal cord and/or nerves for 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, Komanetsky says. Traditionally, neurosurgery practices have used 63030 when there is a diagnosis of herniated nucleus pulposus (HNP), disk bulge or herniation , Komanetsky adds.

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

"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.

Also keep in mind that you should not code a laminectomy and laminotomy at the same level in the same operative setting, because these codes are bundled by the Correct Coding Initiative (CCI). Even though the procedures are often done together, CCI feels 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. You can append modifier 59 (Distinct procedural service), however, if the neurosurgeon performs the laminotomy at a different level or side than the laminectomy. You can even add modifier 22 (Increased procedural services) to 63047 at the same level/side if the physician documents sufficient additional work.