Neurosurgery Coding Alert

Question: Please elaborate the appropriate way to bill a Bilateral Revision Decompressive Hemilaminectomy from T12-S1. New MUE in effect April 1 only allow for 63044 with maximum of 4 units. CPT® doesn’t have a thoracic or sacral code.

Alaska Subscriber

Answer: The multilevel thoracolumbar decompression you describe is unlikely to represent multilevel re-exploration discectomies, The code series describing unilateral or bilateral laminecotmies for decompression are 63045 (cervical), 63046 (thoracic) , 63047 (lumbar) and 63048 (each additional level, regardless of spinal region). CPT® specifies four primary and three add–on codes to describe laminotomy for the primary purpose of discectomy. These include the CPT® codes: 63020, 63030, and +63035 for initial surgery and, 63040, 63042, +63043, +63044 for re-exploration surgery. You report an initial laminotomy for discectomy using CPT® code 63020 (cervical) or 63030 (lumbar), with +63035 for each additional cervical or lumbar level the surgeon treats beyond the first. You report re–exploration using CPT® code 63040 (cervical) or 63042 (lumbar). CPT® code 63043 (cervical) should accompany CPT® code 63040 only for each additional level, whereas CPT® code 63044 (lumbar) should accompany CPT® code 63042.

Count the interspaces: For the first interspace the surgeon explores, you should choose either 63040 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, re-exploration, single interspace; cervical) or 63042 (... lumbar). For each additional interspace beyond the first that the surgeon treats, you should report +63043 (... each additional cervical interspace [list separately in addition to code for primary procedure]) or +63044 (... each additional lumbar interspace [list separately in addition to code for primary procedure]).

Check for bilateral procedures: You may append modifier 50 (Bilateral procedure) to laminotomy for discectomy procedures if the surgeon performs the procedure bilaterally, i.e. on both the left and right side of the same interspace. Because CPT® specifically describes 63040-+63044 as unilateral procedures, you should append modifier 50 if the surgeon performs the exploration bilaterally (that is, on both the left and right side of the same interspace). You can thus get an additional compensation if the surgeon operates on both the left and right portions of the spine at the same interspace.

Since multilevel discectomy is unusual, the MUE limit the number to four, which is already a greater number than typically seen clinically.