Neurosurgery Coding Alert

Question: How do we report when the surgeon does a lumbar laminectomy with facetectomy/foraminotomy? The operative note reads as under:

1. Decompressive lumbar laminectomy L2, L3, L4 complete, partial L1, L5.

2. Facetectomy/Foraminotomy L2-L3, L3-L4, L4-L5 and upper L5-S1 bilateral .

New York Subscriber

Answer: The description provided is not consistent, since the laminectomy that was reportedly performed was only partial at L5, while the facetectomy/foraminotomy is reported at L5-S1. If an S1 foraminotomy with medial L5-S1 facetectomy was in fact performed, you would report codes 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar) for L2-3 and 63048 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure])x3 for L3-4, L4-5, and L5-S1. If the partial L1 laminectomy included decompression of the lateral recess at L1-2, you could report an additional unit of 63048.