Neurosurgery Coding Alert

Question: In a patient diagnosed with cervical fracture C7-T1, our surgeon did a C7-T1 posterior decompressive laminectomy, posterior lateral fusion of C5-T3 and fixation of C5-T3. How do we report this?New York SubscriberAnswer: For the surgery performed in the posterior cervicothoraic spine, the laminectomy reported does not include description of facetectomy and/or foraminotomy. The posterior instrumentation also needs specification for the number of segments that have fixation to differentiate non-segmental from segmental instrumentation.You will report the posterior decompression procedure with code 63001 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy [e.g., spinal stenosis], 1 or 2 vertebral segments; cervical) and append modifier 51 (Multiple procedures). For arthrodesis, you report 22600 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment) and 22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary [...]