Neurosurgery Coding Alert

Question: A few of our physicians document "instability" or "instability with caudal root compression" instead of clearly noting that they're performing a Gill procedure for spondylolisthesis. Does their documentation need to be more specific before we can report 63012?

Utah Subscriber

Answer: No, their notes do not need to specify "spondylolisthesis" before you submit 63012 (Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar [Gill type procedure]). The descriptor for 63012 does not use the verbiage as "e.g.," but does state that it is performed for "spondylolisthesis." Using the ICD-9 diagnostic code for spondylolisthesis (738.4 or 756.12) should be sufficient.