Neurosurgery Coding Alert
Detail All Steps for Spinal Mass Resection
Question: Our surgeon did a cervical laminotomy from C6-T1 with resection of a spinal mass. Plates and screws were used to close the bone. How can we report this procedure?
New Jersey Subscriber
Answer: There is insufficient information to provide specific coding guidance.
The description provided is not sufficient to decide the codes you can use. Consider the following steps before you report the procedure:
Define the location of spinal mass: The location of spinal mass (extradural, intradural/extramedullary, or intradural extramedullary) as well as its nature (neoplastic or non-neoplastic) would be required to determine which regional spine code would be appropriate among codes 63265 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical) - 63285 (Laminectomy for biopsy/excision of intraspinal neoplasm; intradural, intramedullary, cervical).
Review the reconstruction: The nature of the plates and screws (lateral mass fixation or osteoplastic laminectomy with reconstruction) would be required to determine if the fixation is reported as +22842 (Posterior segmental instrumentation [e.g., pedicle fixation, dual rods with multiple hooks and sublaminar wires]; 3 to 6 vertebral segments [List separately in addition to code for primary procedure]), assuming at least 3 points of fixation or +63295 (Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure [List separately in addition to code for primary procedure]).
Consider arthrodesis: Codes 22600 (Arthrodesis, posterior or posterolateral technique, single level; cervical below C2 segment), and +22614 (Arthrodesis, posterior or posterolateral technique, single level; each additional vertebral segment [List separately in addition to code for primary procedure]) make your choices for arthrodesis for the initial and additional levels, respectively.
Do not forget the operating microscope: This type of procedure may also be performed with microdissection +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]).
Tip: You should check if your surgeon also harvested a bone graft.
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Detail All Steps for Spinal Mass Resection
Question: Our surgeon did a cervical laminotomy from C6-T1 with resection of a spinal mass. Plates [...]
