Neurosurgery Coding Alert

Question: How do we code a C1-C5 laminectomy with stealth sequence, occiput lateral mass screw fixation from occiput to C5 and occipital plate?

Ohio Subscriber

Answer: For the laminectomy at the cervical level, you report code 63015 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy [e.g., spinal stenosis], more than 2 vertebral segments; cervical).

You will also report the instrumentation. Since your neurosurgeon is using instrumentation at all levels, you report code 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 that the preoperative planning work of navigation was performed, you may also report 61783 (Stereotactic computer-assisted [navigational] procedure; spinal [List separately in addition to code for primary procedure]). Additionally, bone graft harvest and arthrodesis codes may also be applicable, if performed.