Outpatient Facility Coding Alert

Question: Which would be more appropriate - 63056 or 63030?

Dx. Far Lateral Disk Herniation, left L5-S1.

OP procedure: Far Lateral Transfacetal Diskectomy,
L5-S1.

What was done: Midline incision was made. Muscles stripped from lamina of L5 and S1 area. The Stryker drill was used for perform a foraminotomy with partial facetectomy extending into the facet joints and into the extra foraminal area. Under the microscope, L5 nerve was identified and this was followed laterally in and out to the foramen. There was a calcified area, which was fractured with a downgoing curette to decompress the foramen.

Oklahoma Subscriber

Answer: The correct code to report this procedure is 63056.

If the access to the right far lateral disk requires a transpedicular approach as is usually the case, the appropriate code for the procedure you describe is 63056 (Transpedicular approach with decompression of spinal cord, equina and/or nerve root[s] [e.g., herniated intervertebral disk], single segment; lumbar [including transfacet, or lateral extraforaminal approach] [e.g., far lateral herniated intervertebral disk]) rather than 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically assisted approach]).

 The description for 63056 clearly includes a far lateral disk, and this is not bundled into code 63030, which may also be reported if the surgeon performs posterior approach and hemilaminectomy with decompression.

If the surgeon did not perform a transpedicular approach, modifier -22 may be appended to 63030 only if additional time and effort were required.