Neurosurgery Coding Alert

Question: In a patient with right-sided radiculopathy, our surgeon diagnosed a synovial cyst. Our surgeon did an L4-L5 foraminotomy, decompression of the neural foramina, and synovial cyst removal in this patient. How can we report these services?

Idaho Subscriber

Answer: You should first confirm whether your surgeon did a laminotomy or laminectomy. In laminectomy, your surgeon removes the entire part of the bony lamina; in laminectomy, your surgeon removes only a part of the lamina, usually on one side.

You may consider submitting code 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, lumbar) for the laminotomy. The work units for the cyst excision are bundled into 63030.

Confirming that your surgeon did remove the lamina and performed a foraminotomy, another option includes reporting 63047 (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; lumbar).

However, the most descriptive code to report a laminotomy/laminectomy, unilateral or bilateral, with foraminotomy and excision of synovial cyst is 63267 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar).

ICD-10: You should report the synovial cyst with M71.38 (Other bursal cyst, other site).