Neurosurgery Coding Alert

Question: The neurosurgeon completed bilateral laminotomy to T8-9 and T9-10 in the prone position. The patient's diagnosis was status-post (S/P) revision of fusion and spinal cord decompression. How should we code this since CPT does not have codes for thoracic laminotomy?

Florida Subscriber

Answer: You have two possibly correct options, depending on the exact procedure.

Option 1: If the surgeon does not perform facetectomy or foraminotomy, code with 63016 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy [e.g., spinal stenosis], more than 2 vertebral segments; thoracic).

Option 2: If the surgeon does perform facetectomy or foramintomy, report 63046 (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; thoracic) for the first level. Then include +63048 (... each additional segment, cervical, thoracic, or lumbar [List separately in addition to code for primary procedure]).