Neurosurgery Coding Alert

Question: My neurosurgeon released a tethered cord under the microscope, then excised a dural tag and sent it to pathology. Can we be reimbursed for both services, or are they inclusive?

Michigan Subscriber

Answer: The procedure removes adhesions (tags) from the dura to correct any neurological deficits. Physicians often remove a specimen to send for lab review, but that service is included in the primary procedure.

In this situation, you'll report 63200 (Laminectomy, with release of tethered spinal cord, lumbar) for the cord release and +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]) for the microscope use. Don't report the dural tag removal separately, as it is incidental to the tethered cord release.