Orthopedic Coding Alert

Question: Is there any guideline on when to use 63042 based on the previous surgery date for the same site? For example, may I report 63042 during the global period for the initial surgery? If the initial surgery was a year or more ago, may I still report 63042, or should I go back to a code such as 63030?

North Dakota Subscriber

Answer: According to the AMA, you should report 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, re-exploration, single interspace; lumbar) for re-exploration performed during the global period of the initial surgery and for any time after.

In Principles of CPT Coding, the AMA states: "The term re-exploration simply relates to the repeat surgical exposure of a previous surgical tract and target at the same site on the same patient at a time after an initial surgical procedure(s) was performed. The timeframe associated with the -re-exploration- procedures is not specifically stated. Should re-exploration be required within the operative period of an initial procedure, then the appropriate re-exploration codes should be reported with 78 [Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period] appended."

In other words: The wording suggests that you may report the re-exploration code either within the global period (with modifier 78) or for an undetermined time after the global of the initial exploration.

In addition, the AMA's CPT 2001 Changes provides a clinical example of proper 63040 (- cervical) use that occurs three years after the initial exploration, indicating CPT does not intend for you to revert to an initial exploration code, such as 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]).

Caution: The American Association of Neurological Surgeons (AANS) disagrees and suggests that you should report the re-exploration codes only after the 90-day global period for the initial procedure has expired: "These codes [63040-63043] are intended for disc surgery at a location previously operated upon more than 90 days in the past." The AANS Spring 2001 bulletin states: "The greater work involved in dissection of scar tissue warranted the additional value attributed to these [re-exploration] codes."

Unless your payer tells you otherwise in writing, however, you should consider the AMA's authoritative CPT guidance to trump specialty-society advice.