Orthopedic Coding Alert

Question: My surgeon performed an L4-L5 foraminotomy and synovial cyst removal. The diagnosis is "synovial cyst at the L4-L5 resulting in right-sided radiculopathy." Which CPT code(s) should I report based on the following documentation?

"A high-speed diamond bur was used to perform a foraminotomy. The foraminotomy was carried down to the medial border of the pedicle into the superior lamina of L5. The cyst was encountered, ruptured, and partial cystectomy was performed. Some of the cyst was adherent to the dura, and this was allowed to stay to prevent a dural tear. After adequate decompression, dissection was carried up to the disc space, which was identified. There was quite a bit of fat surrounding the nerve root. The disc was observed and did not appear to be herniated. There was no compression on the nerve root at this level."

California Subscriber

Answer: The surgeon appears to have accessed the spine at the L4-L5 interspace and performed decompression of the neural foramina on the right side with cyst excision. From this documentation, the surgeon appears to perform a laminotomy, not a laminectomy.

Depending on your payer, you should be able to report 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; one interspace, lumbar [including open or endoscopically assisted approach]). You should include the cyst excision in this code.

Check first: Depending on whether the surgeon did remove the lamina, other options include 63047 (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; lumbar) and 63267 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar).

ICD-9: The diagnosis you describe is a degenerative process that typically causes lateral recess compression. Surgeons treat it with medial facetectomy and foraminotomy in addition to excision. You should report the synovial cyst with 727.49 (Ganglion and cyst of synovium, tendon and bursa; other).