Neurosurgery Coding Alert

Question Our doctor performed a T10, T11-12, L1, L2, and L3 laminectomy and foraminotomy with evacuation of epidural hematoma from T10 through L2. How do we report when the operative report reads as follows:

"Lateral spine x-ray was taken to localize T12 and then incision was made from T10 through L2 progressively first at the level of T10, 11, 12. Subperiosteal dissection was carried out and then laminectomy was carried out. The bone was soft and bloody. Hemostasis was obtained with the Bovie as well as the bone wax. Decompression was carried out quickly at the level of T10, 11, 12 and epidural hematoma was large and very compressive, in particular at the level of the injection which seemed to be at T12. Once the decompression was carried out using Kerrison 2 and 3 and the Leksell, the laminectomy was completed at T10 through T12. The incision was then extended through L2 and the same procedure was carried out, removing the lamina and gently removing with the suction without any pressure on the cord, the epidural hematoma which was large, more on the left than the right. Once this was completed, hemostasis was obtained using Gelfoam powder and copious irrigation was carried out. A Jackson-Pratt drain was placed and then closure was carried out in the usual fashion. The patient was stable during the surgery."

Georgia Subscriber

Answer The detailed operative note describes performance of a laminectomy for evacuation of an intraspinal but extradural non-neoplastic mass (in this case, a hematoma). One would not typically perform a foraminotomy in this scenario, and none is reported in the note itself. The procedure would best be described with 63266 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; thoracic). Although the laminectomy extended into the first two lumbar segments, the primary laminectomy occurred in the thoracic segments. If an extensive laminectomy were performed in both the thoracic and lumbar areas, one could either report the primary location (thoracic or lumbar) with the modifier -22 (Unusual procedural services:....) or alternatively report 63267 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar) -59 (Distinct procedural service:...) along with 63266 when the laminectomy included a significant proportion of the lamina in both spinal regions.