Neurosurgery Coding Alert

Question: If our neurosurgeon has to redo a lumbar laminectomy at two interspaces and he explores a fusion mass during the encounter, can we report codes for the laminectomy and the exploration?

Minnesota Subscriber
 
Answer: It depends on the situation and just what the surgeon did during the mass exploration.

Option 1: If the exploration of the fusion extends beyond the area excised for the redo laminectomy, then you can code for both. In this scenario, you should:

- report 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar) for the laminectomy on the first interspace.

- report +63044 (... each additional lumbar interspace [list separately in addition to code for primary procedure]) for the laminectomy on the second interspace.

- report 22830 (Exploration of spinal fusion) for the exploration.

-  attach modifier 59 (Distinct procedural service) to 22830 to show that the procedure was distinctly separate from the laminectomy.
 
Option 2: If, however, the neurosurgeon explores the fusion mass as part of the approach to the nerve root and doesn't biopsy or excise anything beyond what would be removed in the course of the laminectomy, the exploration is a component of the redo laminectomy.

In this scenario, you should only report two CPT codes: 63042 and 63044.