Neurosurgery Coding Alert

Question: In a patient who underwent a lumbar herniated disc excision 2 months ago, our surgeon performed a revision laminotomy with discectomy for a recurrent herniaiton at the same level and same side. How do we report this procedure? Is it right to submit code 63042?

Florida Subscriber

Answer: You should not submit code 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar) for revision laminotomy with discectomy for a recurrent herniation at the same level and same side. This is because the patient is still not out of the 90-day global period. The correct code that you will submit is 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar). You may also append modifier 76 (Repeat procedure or service by same physician or other qualified health care professional) to imply that this was a repeat procedure done by your surgeon done at the same level and same side. In addition, code 63042 is placed in the anatomical hierarchy of unilateral laminotomy for disc surgery and is not intended for revision laminectomy to treat stenosis alone.