Neurosurgery Coding Alert

Question: The neurosurgeon performed a unilateral cervical laminectomy at segments C4-C5 and C5-C6. The surgeon also placed a halo vest during the encounter. Can we report the laminectomy and the halo vest placement?

Minnesota Subscriber

Answer: It depends on whether or not the patient keeps wearing the halo vest after the procedure. If the patient wears the vest for further treatment post-laminectomy, you can:

- report 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 the C4-C5 laminectomy.

- report +63048 (... each additional segment, cervical, thoracic or lumbar [list separately in addition to code for primary procedure]) for the C5-C6 laminectomy.

- report 20661 (Application of halo, including removal; cranial) for the vest placement.

- append modifier 51 (Multiple procedures) to 20661 to show that the halo vest procedure is separate from the laminectomy.
 
But if the neurosurgeon removes the halo vest after the procedure, you should:

- report 63045 for the C4-C5 laminectomy.

- report 63048 for the C5-C6 laminectomy.