Neurosurgery Coding Alert

Question: The day after a level-four office evaluation and management (E/M) service for an established patient, the surgeon performs a transpedicular approach with spinal cord decompression at T11-T12, L1-L2, and L2-L3. How should I report this encounter?

Idaho Subscriber

Answer: You’ll need several codes — and a modifier — to get this encounter correct. On the claim, report:

• 63055 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic) for the T11-T12 approach.
• +63057 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure)) for the L1-L2 approach.
• +63057 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure)) for the L2-L3 approach.
• 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) for the E/M.
• Modifier 57 (Decision for surgery) appended to 99214 to show that the E/M led to the decision to operate.

Explanation: There are codes specifically for the first thoracic and lumbar approaches (63055 and 63056, respectively). Once you get into multiple vertebral spaces in the same area, you cannot use 63055/63056 twice. You must opt for +63057 for each approach beyond the first in the same area of the spine, regardless of whether the additional level is in the thoracic or lumbar spine.