Neurosurgery Coding Alert

Question: How do we report decompression laminectomy at L4-L5? Do we count this as two levels and report 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) and 63048 (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; each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure])?

Ohio Subscriber

Answer: When your surgeon does a laminectomy at L4-L5, it implies that the inferior L4 lamina and superior L5 lamina are removed and a foraminotomy is done at L4-L5 to decompress the exiting nerve root. You will report only one CPT® code 63047. To report a second code, 63048, your surgeon will need to remove more of the lamina at either L4 or L5 and do a foraminotomy with decompression of a different exiting nerve root at a level above or below such as at L3-L4 or L5-S1.