Anesthesia Coding Alert

Question: A 67-year-old patient presents for a hemilaminectomy with decompression of nerve root, partial facetectomy, and excision of herniated intervertebral disc in the cervical spine to treat cervical spondylotic myelopathy (CSM). The anesthesia record indicates the surgeon used a posterior approach with the patient in a prone position. The surgeon did not mention instrumentation in the operative report.

What code is reported for the surgery? Can you also crosswalk the surgical code to the correct anesthesia code?

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Answer: For the hemilaminectomy and herniated intervertebral disk excision involving one cervical interspace, you should report 63020 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical), which covers open and endoscopic approaches.

The crosswalk offers three anesthesia code options for 63020.

• 00600 (Anesthesia for procedures on cervical spine and cord; not otherwise specified)
• 00604 (… procedures with patient in the sitting position)
• 00670 (Anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures))

You can rule out 00604 because the patient was not in a sitting position and 00670, as the surgeon did not indicate that they used instrumentation. Thus, 00600 is the appropriate anesthesia code to report for this case.

Note: In a posterior approach, the surgeon accesses the spinal column through the patient’s back. In order to visualize the vertebra, the surgeon separates the muscles and tissues that surround the spine to expose the vertebra. The patient may be in a prone position (lying face down) or sitting; in this case, the patient was prone.

According to the National Library of Medicine, input from the anesthesiologist regarding whether to use the sitting position is absolutely necessary. If the physicians decide to proceed with the patient in the sitting position, it should be documented as such.

Resource: Review this helpful data at https://pubmed.ncbi.nlm. nih.gov/10325848/.