Neurosurgery Coding Alert

Question: The surgeon removed the spinous process and both lamina, then he decompressed the nerves. The surgeon focused his work on the individual vertebra and the nerve roots exiting through the foramen on either side of the vertebra. When the stenosis was relieved, the surgeon closed the incision in layers. Which CPT^® code should we report for this procedure?

Maine Subscriber

Answer: Assuming this was performed in the lumbar spine, you should report 63047 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar) for this procedure.

Don’t miss: You should report codes 63045 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical); 63046
(… thoracic); or 63047, as appropriate, for the first spinal level the surgeon treats, followed by +63048 (… each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)) for each additional level beyond the first.

Additionally, codes 63045-+63048 are unilateral or bilateral, so you should report the same code, with no modifiers appended, regardless of whether the procedure involves one side or both sides at a single vertebral level.

Caution: If the surgeon performs a laminectomy to relieve spinal cord compression or remove abnormal facets without nerve decompression, you should choose from codes 63001 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical)-63017 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; lumbar) rather than 63045-+63048.