Neurosurgery Coding Alert

Hint: Don’t mix up term “laminectomy” with “laminotomy.”

Spinal surgery can be very challenging to report because your surgeon can perform many different types of spinal surgery. And, along with these numerous procedures, you have numerous code options to choose from. When you code a laminectomy, which is a type of decompression surgery, you will want to read the medical documentation to make sure you always know exactly what your surgeon did.

Read on to learn more.

Pay Attention to Medical Documentation, Code Descriptors

Error 1: You didn’t read the medical documentation carefully, so you aren’t sure whether to report a code from the 63045-+63048 range or the 63001-63017 range.

Solution: Always read the medical documentation and pay attention to the different code descriptors for laminectomies to help you choose the correct code for each case you encounter.

For example, when it comes to 63045 (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; cervical)-+63048 (... each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure), the code descriptors include “facetectomy and foraminotomy, along with decompression of the spinal cord, cauda equina and/or nerve roots.”

Remember: 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), explains Gregory Przybylski, MD, past chairman of neurosurgery and neurology at the New Jersey Neuroscience Institute, JFK Medical Center in Edison, New Jersey.

Codes 63001-63017: On the other hand, if you need to report a laminectomy with exploration and or decompression of the spinal cord and or cauda equina, without a facetectomy, foraminotomy, or discectomy, you should report a code from the 63001-63017 range. For one or two vertebral segments, you can turn to the following codes:

• 63001 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical)
• 63003 (…thoracic)
• 63005 (…lumbar, except for spondylolisthesis)
• 63011 (…sacral).

And, if the procedure involves more than two vertebral segments, you would choose from the following codes:

• 63015 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), more than 2 vertebral segments; cervical)
• 63016 (…thoracic)
• 63017 (…lumbar).

“The important difference between codes in the 63001-63017 range and 63045-+63048 range is the degree of bony removal,” Przybylski explains. “Codes 63001-63017 are central canal decompressions, which do not involve facetectomy or foraminotomy. In contrast, codes 63045-+63048 described unilateral or bilateral posterior decompressions that include facet removal and foraminotomy. Simply put, the first group of codes reflect midline central canal decompression, whereas the second group reflects decompression further laterally beyond the central canal.”

Don’t miss: For a lumbar laminectomy for spondylolisthesis secondary to spondylolysis, you would report 63012 (Laminectomy with removal of abnormal facets and/or pars inter-articularis with decompression of cauda equina and nerve roots for spondylolisthesis, lumbar (Gill type procedure)).

Look for These Details in Decompression Procedures

Error 2: The surgeon didn’t include important details in the op report.

Solution: If the surgeon performs a decompression of the nerve or spinal cord, you want to make sure they include the following details in the body of their op report, said Lynn M. Anderanin, CPC, CPMA, CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois, in the recent Virtual HEALTHCON session, “Spinal Surgery Update 2020:”

• A description of the nerve or nerve roots they are decompressing
• The number of nerve roots they are decompressing, whether it’s single or multiple
• Whether or not they are decompressing the spinal cord

“It’s very important that [the surgeon] tells us what nerve or nerve roots are being decompressed,” Anderanin explains.

Clearly Distinguish Between Laminectomy and Laminotomy

Error 3: You mixed up the terms “laminectomy” and “laminotomy” when you were reading the op report.

Solution: Although laminectomies and laminotomies are both spinal decompression surgeries, they are different procedures, so you will report different codes for these procedures.

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

On the other hand, 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).

When comparing a laminotomy versus a laminectomy, Anderanin offers this advice.

When the surgeon removes less than 50 percent of the lamina, and you are coding for disc disorders, then this would be considered a laminotomy.

And, if you are coding for a laminectomy, then you are coding for stenosis, and the surgeon will have removed more than 50 percent of the lamina.

Another way to look at the difference between laminotomy and laminectomy is the intended purpose, Przybylski explains.

“Laminotomy codes 63020-+63044 describe unilateral procedures whose target is a disc displacement,” according to Przybylski. “In contrast, laminectomy codes 63045-+63048 describe unilateral or bilateral procedures whose target is stenosis. Since stenosis involves anatomical structures in which two laminae overlap, a surgeon performing a decompression for spinal stenosis and reporting 63045-+63048 will typically remove less than the full lamina of each of the two overlapping levels.”

Editor’s note: Want more great info like this? You can now register for the upcoming 2020 HEALTHCON regional conferences: https://www.aapc.com/medical-coding-education/conferences/. Also, early bird registration is open for 2021 HEALTHCON in Dallas. Visit www.aapc.com for more info.