Neurosurgery Coding Alert

Question: Our neurosurgeon performed a facetectomy at C7 and T1 to allow for arthrodesis. Would this step be considered "access," or can we report 63045 in addition to the arthrodesis?

California Subscriber

Answer: The correct answer depends on whether your physician completed facetectomy simply for access to accommodate the arthrodesis. If the answer is yes, you cannot separately report the facetectomy because the surgeon didn't perform the associated decompression.

If, however, the surgeon did not use the facetectomy for access but rather for nerve root decompression, you can submit 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). You'll also report the applicable arthrodesis code, such as 22600 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment).