Neurosurgery Coding Alert

Question: Our surgeon treated a patient who was four months status post a right-sided L5-S1 laminotomy and foraminotomy for excision of a right herniated disc. The patient started getting symptoms on her left side, so the surgeon returned the patient to the OR and re-explored the right side, then performed a laminotomy, foraminotomy and discectomy at L5-S1 on the left side for the degenerated disc. During the surgery, the surgeon re-explored the right side but decompressed the left side. How should I report this service?

Michigan Subscriber

Answer: For the re-exploration of the right side, you should report 63042-RT (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; lumbar; Right side).

In addition, you should report 63030-59-LT (Laminotomy [hemilaminotomy], 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]) for the decompression on the left side.

 -- Answers to You be the Coder and Reader Questions were reviewed by Gregory Przybylski, MD, director of neurosurgery at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, N.J.