Neurosurgery Coding Alert

Follow these steps to properly code for thoracic hemilaminectomies.

If you or your provider performs laminectomies and hemilaminectomies on a regular basis, you’ve probably come across the dilemma on how to correctly code thoracic hemilaminectomies.

Refresher: First, let’s clear up some confusion by outlining the differences between a laminectomy and a hemilaminectomy. A laminectomy is a procedure in which the surgeon removes both lamina from the vertebrae. A hemilaminectomy, on the other hand, involves the removal of only one side of the lamina. “Laminectomies and hemilaminectomies are generally performed as a means of decompressing the spinal cord and/or nerve roots — typically as a result of spinal stenosis, disc degeneration, or disc herniation,” relays Meagan Strauss, CPC, CEMC, Coding Coordinator for The NeuroMedical Center Clinic in Baton Rouge, Louisiana.

Continue reading for a complete breakdown of the thoracic hemilaminectomy coding process.

Don’t Rely on 63046 as an Alternative

While coding a cervical and lumbar hemilaminectomy for discectomy is relatively simple, the lack of inclusion of a dedicated posterior unilateral thoracic discectomy code makes the coding process a little trickier. Some coders might resort to using code 63046 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; thoracic). Based on the description of the thoracic procedure, it may not be entirely clear to some that applying a laminectomy code to a hemilaminectomy (unilateral) code is inherently incorrect.

“The 63045-63048 series describe laminectomy for spinal stenosis,” explains Gregory Przybylski, MD, interim chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison.  “These are almost always done bilaterally. The lamina can be considered a ‘unilateral’ structure, they are paired left and right, but the term laminectomy is used when both sides are removed.”

“A hemilaminectomy, on the other hand, is removal of the lamina on one side or the other. Therefore, the term ‘unilateral laminectomy’ is used interchangeably with hemilaminectomy. Hemilaminectomy is not intended to represent partial removal of a unilateral lamina (that is called laminotomy), but rather intended to represent complete removal of the lamina on one side or the other,” details Przybylski.

Even with these contrasting definitions in place, there is a common belief in the neurosurgical coding community that a coder can opt to code a thoracic hemilaminectomy by simply applying modifier 52 (Reduced services) to the code. Since 63020 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical) and 63030 (… 1 interspace, lumbar) are unilateral codes intended for discectomy, which cannot be performed without at least a laminotomy (except in unusual circumstances), you should not make the false assumption that the use of modifier 52 on code 63046 will accurately describe the surgeon’s work on a thoracic hemilaminectomy.

Check Out This Clinical Explanation

The reason that an equivalent unilateral laminotomy (hemilaminectomy) for discectomy was not developed for the thoracic region is clinically-related.

How? Direct posterior approaches for cervical and lumbar disc herniations are quite common, as the target herniation is typically posterolaterally located, allowing for direct posterior access. In the thoracic spine, thoracic disc herniations are often closer to midline with calcifications. Given the comparatively smaller diameter of the spinal canal and the vulnerability of the enclosed thoracic spinal cord to manipulation, other techniques for addressing symptomatic thoracic disc herniations have been developed (eg. CPT^® 63055 for the transpedicular approach and CPT^® 63064 for the costovertebral approach) to reduce the risk of iatrogenic thoracic cord injury.

Resort to Coding Unlisted

Based on the above justification, it’s clear there is no existing CPT^® code that accurately describes the work that a thoracic hemilaminectomy entails. In the circumstances in which your provider performs a thoracic hemilaminectomy for a direct posterior approach to discectomy, you may opt for the unlisted code 64999 (Unlisted procedure, nervous system).

Remember: Just like modifier 52, using an unlisted code will require a submission of documentation in order to receive payment. In addition to the operative note and a supplementary note justifying the procedure, a personal note written by the performing surgeon can go a long way in cases like this.

Additionally, you will want to include code 63020 or 63030 as a comparison code in order to receive similar reimbursement. If the surgeon feels that the thoracic hemilaminectomy required more work than what is described in the cervical and lumbar hemilaminectomy codes, they should provide any and all documentation available supporting their case.