Neurosurgery Coding Alert

Question: To provide spinal cord and nerve decompression, the surgeon removed the spinous process and left lamina of the third cervical vertebra (C3), as well as the spinous process and left and right laminae of the fourth cervical vertebra (C4). What codes should I report for this procedure?

Wisconsin Subscriber

Answer: Assuming that two interspace decompressions were performed (i.e. the C34 and C45 interspaces), you should report 63045 (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; cervical) for the first spinal level (C3) the surgeon treats followed by +63048 (... each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) for the subsequent spinal level (C4).

Caution: Even though the surgeon removes only a unilateral lamina from C3 and bilateral laminae from C4, you report each code “as is” with no modifiers appended. The documentation should include the nerve root(s) decompressed (since two interspace decompressions are being reported) as well as the work of partial or complete facetectomy and, if performed, foraminotomy and discectomy. These codes are reported for either unilateral or bilateral laminectomy, and therefore modifier 50 (Bilateral procedure) for bilateral procedure is not applicable.