Neurosurgery Coding Alert

Question: What is the proper coding if a neurosurgeon performs a re-exploration microdiskectomy on a patient at level L4-5 (unilateral) and an initial microdiskectomy at level L5S1 (unilateral) during the same operative session? My understanding is that Medicare does not reimburse when 63030 (laminotomy, lumbar, initial surgery) and 63042 (laminotomy, lumbar, re-exploration) are coded for the same operation. Further, 63035 (each additional interspace, cervical or lumbar) is only for use with 63030, and not 63042, and there is no additional level code for 63042. How can a neurosurgeon gain reimbursement under these circumstances? This leads to a follow-up question: If both levels in the given example were re-explorations, what is the correct coding?

Texas Subscriber

Answer: According to the national Correct Coding Initiative (CCI) rebundling edits, Medicare will not allow 63030 (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically-assisted approach]) and 63042 (laminotomy [hemilaminectomy], with decompression of never root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, re-exploration; lumbar) when performed at the same location.

Codes 63030 and 63042, however, should be paid when performed at different lumbar levels (as in the given example), or even on opposite sides of the same vertebral level because they are both unilateral codes. In the first scenario, code 63042 and 63030-59 (distinct procedural service) to indicate the separate level for initial hemilaminectomy. To correctly code for a reoperative laminectomy at two levels use 63042 and 63042-51.

Laminectomy procedures have add-on for additional levels because it actually may be easier for the neurosurgeon to access additional levels after removing bone from the first.

Reoperative codes such as 63040 (laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk, re-exploration; cervical) and 63042 often pay significantly more than initial surgery codes because the second surgery is usually more difficult than the first. In the case of a microdiskection, when a decompression already has been performed on a vertebra, a large amount of scar tissue grows around the bone. If a patient suffers from a recurrence of a herniated disc (722.7), an exostosis (726.91), or other malady resulting in the nerve once again experiencing compression, the scar tissue build-up may make it difficult (even with MRI results) for the neurosurgeon to identify the complex anatomical structure in question (where the nerve root reaches out of the spinal cord to make its way through the foramen), to isolate the aberrant anatomy, and to perform the necessary procedure. The scar tissue may harden and become fibrotic over time. Some doctors describe working through such scar tissue as trying to dissect through clay.

This is another reason why 63040 and 63042 are unilateral (each side of the vertebrae can be operated on and billed independently) and not bilateral codes (paying one fee for both sides). Neurosurgeons should note that modifier -50 (bilateral procedure) can be appended when both the left and right sides of the vertebrae are operated on.

Coding for this procedure when several levels are performed bilaterally can vary. The initial level may be coded 63042-50. At the second level, it may be coded 63042-50-51 (multiple procedures). Generally, a neurosurgeon will be paid at 150 percent for the initial level and 75 percent for the second level.

Or the second level may be coded 63042-51-LT (left side) followed by 63042-51-RT (right side). Some carriers may pay the second level at 100 percent (i.e., at 50 percent for each side) when it is coded in this manner.