Neurosurgery Coding Alert

Question: Our neurosurgeon completed posterior cervical laminectomy (C4, C5, and C6), partial bilateral laminectomy (C3), partial bilateral laminectomy (C7), and bilateral decompression and foraminotomies (C3-4, C5-6, C6-7). He also performed medial facetectomies at each level. How should we code everything?

Iowa Subscriber

Answer: As involved as the procedure was, your coding is actually quite simple: begin with 63045 (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; cervical) for C3-4. Then add +63048 (... each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure]) three times to represent the laminectomies and foraminotomies at the additional levels C4-5, C5-6 and C6-7.