Neurosurgery Coding Alert

If the neurosurgeon performs the procedure bilaterally, don’t forget to append modifier 50.

When your neurosurgeon performs a laminotomy to treat herniated intervertebral discs, you should ensure you are familiar with info like the differences between a laminotomy and a laminectomy, which CPT^® codes to report for a laminotomy, and when you should appropriately append modifier 50 (Bilateral procedure) to the service.

Answer the following FAQs to jumpstart your laminotomy skills.

Distinguish Between Laminotomy and Laminectomy to Clear up Confusion

FAQ 1: The terms laminotomy and laminectomy look so similar. What is a laminotomy and how is it different from a laminectomy?

Answer 1: Although laminectomies and laminotomies are distinct procedures in CPT^®, the similarities between them often cause confusion.

Laminotomy defined: A laminotomy involves the partial removal of the upper and lower portions of adjacent laminae, such as the laminae on either side of a vertebral interspace to perform a lateral recess or foraminal decompression.

Hemilaminectomy defined: A hemilaminectomy involves removal of the entire lamina on one side of thespine, and this term is often used interchangeably with laminotomy.

In fact, CPT^® has a parenthetical after laminotomy describing “hemilaminectomy” in the long descriptor of code 63020 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical), says Gregory Przybylski, MD, past chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

While there is overlap between these terms, they are not synonymous, Przybylski adds. This adds to the confusion when faced with choosing the appropriate decompression code.

Laminectomy defined: During a laminectomy, the neurosurgeon removes the spinous process (the bony projection on the back of the vertebrae) and both lamina (the posterior, broad plates of bone that complete the “arch” of the vertebrae and enclose the spinal canal). However, CPT® uses laminectomy as the definition of unilateral (correctly termed hemilaminectomy) or bilateral decompression in the long descriptor of 63045 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; cervical), according to Przybylski.

Sharpen Your Primary Laminotomy Reporting Skills

FAQ 2: What are the primary laminotomy CPT^® codes?

Answer 2: CPT^® identifies four primary codes to describe laminotomy for the primary purpose of discectomy, which is an excision, in part or whole, of an intervertebral disc. These are all unilateral procedure codes to which modifier 50 may be applied when performed bilaterally at the same interspace level, Przybylski adds.

When you are reporting an excision of a herniated intervertebral disc, you would choose either 63020 or 63030 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar) as the primary laminotomy code, depending upon whether the neurosurgeon performed the procedure in the cervical or lumbar region.

For a re-exploration, you should report the following codes:

• 63040 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical)
• 63042 (… lumbar).

Don’t miss:  “The re-exploration hemilaminotomy and discectomy codes 63042-+63044 are intended for re-exploration discectomy and not for ex-exploration laminectomy for stenosis,” says Gregory Przybylski, MD, past chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey. “These codes are unilateral codes and follow in sequence the primary unilateral laminotomy for discectomy codes.”

Example: The patient developed recurrent left L5 radiculopathy from a recurrent herniated L4-5 disc after prior surgery at the same level as in the distant past. Your surgeon opens the old incision, exposes the remaining left L4 hemilamina, and excises the recurrent disc displacement. In this case, you would report code 63042.

Note: You report one unit of code 63020 (63040 for recurrence) or 63030 (63042 for recurrence) for the excision of the herniated disc in a single interspace in the cervical or lumbar regions, respectively.

“The re-exploration discectomy codes should only be reported when the prior discectomy was performed at least three months earlier,” Przybylski says. “If the recurrence prompts re-exploration within the 90-day global period, the primary discectomy code should be reported with the 76 modifier.”

Mark Down These Add-On Codes for Additional Interspaces

FAQ 3: What are the add-on laminotomy CPT^® codes?

Answer 3: CPT^® identifies three add-on laminotomy codes. For each additional interspace where a primary discectomy was performed, either in the cervical or lumbar region, you should report code +63035 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure)) in addition to 63020 or 63030.

“This follows the convention of posterior segmental spinal procedures, in which the adjacent level treatment is reported with the same code, regardless of spinal region,” Przybylski says.

There are two add-on codes for re-exploration procedures, one for the cervical region and a second for the lumbar region. They are as follows:

• +63043 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure)). You should report this cervical code with 63040 for each additional level.
• +63044 (… each additional lumbar interspace (List separately in addition to code for primary procedure)). You should report this lumbar code with 63042 for each additional level.

Don’t Miss Modifier 50 for Bilateral Laminotomy

FAQ 4: What is the importance of modifier 50 when it comes to laminotomy codes?

Answer 4: In CPT^®, parenthetical notes under 63020 through +63044 instruct you to report the appropriate code with modifier 50 for bilateral procedures — if the neurosurgeon performs the procedure bilaterally on both the left and right side of the same interspace.

Because CPT^® specifically describes 63030 through +63044 as unilateral services, you should append modifier 50 if the surgeon performs the procedure bilaterally. You will get an additional compensation if the surgeon operates on both the left and right portions of the spine at the same interspace.