Neurosurgery Coding Alert

Question: The surgeon performed a partial C4 corpectomy (30-40 percent) and a partial C5 corpectomy (50-60 percent) to safely retrieve disc fragments that migrated inferiorly behind the C4 and C5 bodies. Should we report 63081 or 63300?

Florida Subscriber

Answer: Since the surgeon documented that he performed the corpectomy as a means of relieving decompression on the spine, you would likely report 63081 (Vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment), and not 63300 (Vertebral corpectomy (vertebral body resection), partial or complete, for excision of intraspinal lesion, single segment; extradural, cervical), which does not apply to disc displacements.

Caution: The documentation in this scenario does not meet the criteria to code for 63081 for the partial corpectomy of the C4 vertebral body. Since the surgeon did not remove at least 50 percent of the vertebral body, you would be unable to apply 63081 to this portion of the surgery. However, since the surgeon did resect 50 percent or more of the C5 vertebral body, you may code for this portion of the surgery with 63081, assuming that the resection was more than 50 percent of the volume of the vertebral body and not the “cross-sectional area,” the latter of which more likely would represent an extended discectomy.

Removal of 40 to 50 percent of cervical vertebral body: If the surgeon documented the removal of 40 to 50 percent of a cervical vertebral body, then remember that specificity is extremely important. If the surgeon is ambiguous as to exactly what portion of the vertebral body the resection entails, you should not make the assumption that the surgeon reached the 50 percent threshold of the vertebral body volume. Instead, you should ask the surgeon for clarification to determine the full extent of the surgeon’s work. The same rule applies to thoracic and lumbar corpectomy coding, although the threshold for reporting corpectomy requires in excess of 1/3 of the vertebral body volume. The surgeon needs to be as detailed as possible in documenting the percentage of the resected vertebral body.