Neurosurgery Coding Alert

Open-door laminoplasty is a unique neurosurgical procedure for which there is no dedicated CPT code. However, by supplying appropriate documentation and properly applying unlisted-procedure codes and modifiers, neurosurgery practices can be sure to receive their deserved reimbursement.

Open-door laminoplasty is an alternative treatment for spinal stenosis (723.0, cervical; 724.00-724.09, Other than cervical), or narrowing of the spinal canal. Degeneration of the vertebral column and associated soft tissue can compress the spinal cord, leading to pain, numbness or loss of motor abilities. Although a viable option, decompressive laminectomy (63001-63017) during which the surgeon removes the entire lamina at one or more vertebral segments to reduce pressure on the spinal cord often results in complications such as instability, kyphotic deformity and postlaminectomy syndrome, which may require fusions that severely curtail mobility.

In contrast, says Donald D. Dietze, MD, a surgeon with the North Institute in Covington, La., open-door laminoplasty decompresses the spinal cord while retaining structural support for the vertebral column. The surgeon cuts through the lamina on one side of the spinous process (the tips of which are removed) at the affected levels and notches the lamina on the opposite sides to create a "hinge" on which to open the posterior segment of the vertebrae and release the spinal cord. The surgeon then places bone grafts in the space left by the "open door," which are secured with titanium plates, to provide structural stability and a place for muscles to reattach.

CPT contains no dedicated code to describe open-door laminoplasty. Therefore, Eric Sandham, CPC, compliance educator for Central California Faculty Medical Group, a group practice and training facility associated with the University of California at San Francisco in Fresno, suggests that coders report this procedure using 64999 (Unlisted procedure, nervous system) for the initial vertebral level at which the procedure takes place. He further advises reporting additional levels beyond the first using the same code with modifier -51 (Multiple procedures) appended. "Because of the careful and extensive work involved, each additional level deserves additional payment," he says. And you should report the structural allograft separately using 20931 (Allograft for spine surgery only; structural).

Although the procedures are associated, an open-door laminoplasty is more complex and time-consuming than a typical laminectomy and includes elements of both excision and fusion. For this reason, and because CPT and many coding experts advise against using the "next best" code when reporting a procedure without a dedicated CPT descriptor, do not report 63001-63015 for open-door lamino-plasty. Even if you append modifier -22 (Unusual procedural services) to the claim, the payer is unlikely to give it the consideration and scrutiny it deserves meaning you will not likely receive the payment you deserve, either.

Reporting an unlisted-procedure code will get the payer's attention, but without proper documentation you'll likely receive a rejection or minimal reimbursement. "The operative report must reflect the additional work and effort involved as much as possible. The more detailed the dictation, the better," Sandham says.

To improve the payer's understanding, include a separate letter that explains the nature of the procedure and the precision and time involved. Such documentation takes time, but it's worth the effort in this case. Note every step in the procedure required for each vertebral level so the payer can make an informed judgment about payment, including: