Neurosurgery Coding Alert

Question: Our insurer is denying 22630 and 63047 during the same session. Why?

Nevada Subscriber

Answer: The payer is probably denying your claims because the National Correct Coding Initiative bundles 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) to 22630 (Arthrodesis, posterior interbody technique ... single interspace; lumbar). And, CPT specifically states that arthrodesis includes laminectomy, facetectomy and diskectomy.

But if the surgeon performs the laminectomy and arthrodesis at different locations, you may report both procedures. The NCCI allows for this possibility by including a "1" modifier indicator with the edit bundling 63047 to 22630. This means that you may use a modifier (in this case, modifier -59, Distinct procedural service) "to differentiate between the services provided" at different times or at different locations on the body.

For example, the surgeon performs arthrodesis - with associated laminectomy and diskectomy - at L4/L5. At the same time, the surgeon undertakes laminectomy/facetectomy for decompression at L3. Because the laminectomy occurred at a location distinct from the arthrodesis, you should claim 22630, 63047-59.

And CPT allows separate billing of 63047 when the surgeon performs nerve root decompression (in other words, when the surgeon performs more than just an approach for fusion), although many payers construe NCCI to prohibit this, as well. If the surgeon clearly documents the patient's condition and the extent of the decompression, you will have a good case for modifier -59 on appeal.

- Clinical and coding expertise for You Be the Coder and Reader Questions provided by Eric Sandham, CHC, CPC, compliance manager for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno.