Neurosurgery Coding Alert

Question: One of the patients treated by our neurosurgeon had a pathologic fracture of L4 with inversion of left pedicle and foramen and compression of nerve root at L3-L4. The following procedures were done for nerve compression with epidural mass at L3-L4:

1. Left L3 hemilaminotomy with facetectomy and microdiskectomy
2 Removal of left L3-L4 epidural mass
3. Partial L4 corpectomy

Please suggest the CPT® and diagnosis codes.

New Jersey Subscriber

Answer: There is insufficient information in the scenario to provide specific coding guidance. For example, the nature or the epidural mass in not described nor is the approach/extent of removal for performing the partial L4 corpectomy.

There is also a significant amount of overlap among the three procedures described. CPT® 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disc], single segment; lumbar [including transfacet, or lateral extraforaminal approach] [e.g., far lateral herniated intervertebral disc]) includes all three of these components.

You might report the ICD-9 code 733.13 (Pathological fracture of vertebrae) for the fracture. It is unclear what role the disc was playing, but one may also report 722.10 (Displacement of lumbar intervertebral disc without myelopathy).