Neurosurgery Coding Alert

Question: How should I code re-exploration of L3/4, L4/5 with revision of L3 through L5 hardware, and L2-L3 decompression?

Answer: The scenario is incompletely detailed to provide definitive guidance. If the initial procedures at L34 and L45 were discectomies, the re-exploration would be reported with 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root [s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar) for (L3/4) and 63044 (each additional lumbar interspace [list separately in addition to code for primary procedure]) for (L4/5). However, if the original procedure was a decompression by laminectomy and facetectomy, the re-exploration would be reported with the same 63047 and 63048, perhaps with the -22 modifier to reflect any significant additional work.

For the revision, look at 228xx.... Since the scenario did not differentiate segmental or non-segmental instrumentation, whether extension of instrumentation was performed, or whether removal of instrumentation without replacement was performed one can't specify the correct code. You would bill 22830 (Exploration of spinal fusion) and append modifier 59 (Distinct procedural service) if this was performed to determine whether the presumed original arthrodesis had succeeded. Keep in mind that CMS bundles exploration of fusion with many arthrodesis or instrumentation revision codes.

To accurately report the L2/3 decompression, you will need to provide more information. If it was a facetectomy, foraminotomy and laminectomy, as for stenosis, you would report 63047 (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; lumbar).

If the procedure primarily involved discectomy, you would report 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically assisted approaches; 1 interspace, lumbar). If only a single segment central decompression was performed without lateral recess decompression, 63005 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy [e.g., spinal stenosis], 1or 2 vertebral segments; lumbar, except for spondylolisthesis). You may need to add -59 to the code chosen, depending on the codes used for the revision to identify the separate level of decompression that was performed.