Neurosurgery Coding Alert

Question: Our surgeon did a bilateral decompression laminectomy at L2-L5 along with bilateral foraminotomies at each level from L2-L5. Do we bill for foraminotomies by interspace where the nerve exists, i.e. 63048 x3 or by level of decompression, i.e. 63048 x2? How much number of units of 63048 can we report?

Ohio Subscriber

Answer: You need to determine the number of nerve root levels that were decompressed. If your surgeon does bilateral decompression laminectomies L2-L5 with facetectomy and foraminotomy at L3-L5, i.e. three levels, you report code 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 two units of +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]). Code +63048 is an add-on code. If your surgeon also removed sufficient bone to perform an L2 foraminotomy, than you may report 63048 for a third unit.