Neurosurgery Coding Alert

Question: The surgeon performed a Gill procedure at L5-S1 and performed a wide foraminotomy of the L5-S1 roots bilaterally for decompression and facetectomies. He also documented L5-S1 osteotomies for correction of spondylolisthesis. When should we bill the Gill procedure versus a decompression when the surgeon performs both procedures at the same level?

Connecticut Subscriber

Answer: Your correct choice is to code the Gill procedure with 63012 (Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar [Gill type procedure]).

Explanation: The Gill procedure includes decompression. In this example, surgery involves removing the spinous process of L5, the L5 lamina, and the inferior L5 facets. The surgeon frees and excises the ligamentum flavum at the L5 level and decompresses the fifth lumbar nerve root. He completes decompression, removing any additional boneand other structures that might be applying pressure to the nerve roots.