Neurosurgery Coding Alert

Question: If the surgeon performs a right laminotomy at L4-L5 and a left laminotomy at L2-L3, should I report 63030 with 63035, or 63030 with 63030-59?

Answer: For a right L4-L5 laminotomy and left L2-L3 laminotomy, you should report one unit each of 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, lumbar [including open or endoscopically assisted approach]) and +63035 (... each additional interspace, cervical or lumbar [list separately in addition to code for primary procedure]).

And, you may append modifier RT (Right side) to 63030 and LT (Left side) to 63035 for greater specificity.

You should report only one unit of 63030 per claim. For all interspaces the surgeon treats beyond the first, whether on the same or a different side (right-right vs. left-right) you must call on the add-on code 63035.

If the surgeon performs laminotomy on the left and right side of the same interspace, however, you may report a single unit of 63030 with modifier 50 (Bilateral procedure) appended. For instance, for right L4-L5 and left L4-L5 laminotomy, report 63030-50.