Neurosurgery Coding Alert

Question: The neurosurgeon performed a laminectomy with facetectomy/foraminotomy on the first and second cervical vertebrae of a patient with lateral cervical stenosis. She removed spinous process and right lamina of the first vertebra (C1) and removed both laminae of the second vertebra (C2). Do I need to apply a modifier to the C1 laminectomy, since the neurosurgeon did not remove spinous process from both laminae?

Oklahoma Subscriber Answer: Because the codes for laminectomy are bilateral or unilateral, you will not need any modifiers for this encounter. On the claim,

- report 63045 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; cervical) for the initial (C1) laminectomy.

- report +63048 (... each additional segment, cervical, thoracic or lumbar [list separately in addition to code for primary procedure]) for the second (C2) laminectomy.

- attach ICD-9 code 723.0 (Spinal stenosis in cervical region) to 63045 and 63048 to represent the patient's cervical stenosis.

Explanation: Though the neurosurgeon only removed a single lamina from the first vertebra, you always report the laminectomy codes as is.