Neurosurgery Coding Alert

Question: Our physician performed a pair of discectomies: one at C5-C6 and another at C7-T1. Should I report two cervical discectomies, two thoracic discectomies, or one of each?

Montana Subscriber
 
 Answer: When your neurosurgeon conducts discectomies across two regions, you should code according to the region where she performed the majority of the work.
 
In your scenario, the surgeon worked on C5-C6 and C7-T1, meaning the majority of the work was done in the cervical region, which you would report as:
 
- 63075 (Discectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophy-
tectomy; cervical, single interspace) for the C5-C6 discectomy
 
- +63076 (... cervical, each additional interspace [list separately in addition to code for primary procedure]) for the C7-T1 discectomy.

Coding across regions gets trickier when the surgeon performs equal amounts of work in each region. In these instances, many coders choose to code anatomically from top to bottom. For example, if the surgeon performed a discectomy at C7-T1, you would code for a cervical procedure because the operative exposure is cervical.
 
However, your insurer may not endorse the -top to bottom- coding solution. If you have any doubts about inter-regional discectomy coding, ask the surgeon what approach she used. You may also have to call the insurer to ask how it wants you to code these claims.