Neurosurgery Coding Alert

Question: Patient presented with symptoms that resulted in a L-MRI which revealed an extradural lesion at the L5-S1. The concern was for a myeloma. Our neurosurgeon planned a laminectomy (63277) for removal of this "lesion." He performed a L5-S1 bilateral laminectomy and found no obvious tumor, only bony overgrowths and a hypertrophied ligamentum flavum and cartilaginous overgrowth. He removed this to decompress the cord and the spinal nerve roots. Pathology report showed normal tissue. How would I code this? Should I use 63047?

New York Subscriber

Answer: Because the neurosurgeon did not find a "lesion," and you did not mention a facectomy or foraminotomy, you might try 63005 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy [e.g., spinal stenosis], 1 or 2 vertebral segments; lumbar, except for spondylolisthesis) for the laminectomy.

Watch out: Although the neurosurgeon decompressed the spinal canal and got rid of the ligamentous overgrowth that caused the compression, you should not 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) because this code contains "facetectomy and foraminotomy." You may, however, report 63047 if the surgeon documented facetectomy and foraminotomy.

 As for your diagnosis, check with your op note. You are likely to report osteophytes (721.8, Other allied disorders of spine), 724.8 (Other symptoms referable to back), and 724.02 (Spinal stenosis, other than cervical; lumbar region).