Neurosurgery Coding Alert

Question: A window laminotomy was performed at L5. Foraminotomies were then performed at L5-S1 and S1-S2. How should I report this? No codes address the sacral foraminotomies.

Nebraska Subscriber

Answer: The sacrum is comprised of several naturally "fused" vertebrae. Nerve roots exit through sacral foramina, so a foraminotomy in this area can be performed.
 
In this case, because a more precise code is not available, report 63030 (laminotomy [hemilaminectomy], with decompression of nerve roots[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach) and append modifier -22 (unusual procedural services) to account for the work involved in the additional foraminotomies.  
 
Use 63035 ( each additional interspace, cervical or lumbar [list separately in addition to code for primary procedure]) with modifier -22 for the creation of additional "windows" in the sacrum to reach the nerves. Provide clear documentation with the claim that thoroughly explains the surgery, the estimated percentage of additional work involved in the foraminotomies, and an appropriately increased fee, e.g., a 30 percent higher fee for a surgery involving 30 percent more work than is typical.
 
If a large part of the sacrum is removed, try reporting 63011 (laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or diskectomy, [e.g., spinal stenosis], one or two vertebral segments; sacral) instead of 63030-22. Be aware that this code specifically excludes foraminotomy in the description, so you should consult with the insurer before assigning it.

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