Neurosurgery Coding Alert

Question: Our surgeon did a complete microdiscectomy between T7 and T8 to remove the disc herniation compressing the dura. Then a lateral plate was placed. How can we report this procedure?

Pennsylvania Subscriber

Answer: The scenario does not provide information regarding the approach used.  If a posterior approach was performed, you may report code 63055 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disc], single segment; thoracic) for the decompression of the cord in the thoracic segment or 63064 (Costovertebral approach with decompression of spinal cord or nerve root[s] [e.g., herniated intervertebral disc], thoracic; single segment) if a costovertebral approach was used.  If an anterior approach was used, .you would report 63077 (Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; thoracic, single interspace).  Placement of a lateral plate would be unusual without an arthrodesis, which was not a part of your reported procedure.  Lateral vertebral plates affixed to the vertebral bodies would be reported with +22845 (Anterior instrumentation; 2 to 3 vertebral segments [List separately in addition to code for primary procedure]).