Count Segments to Code Laminectomy Properly
Question: How should I code the following encounter? A patient with lumbar stenosis without neurogenic claudication at L4-S1 reports for surgery. After prepping the patient, they are placed face down. The physician makes a midline incision overlying the affected vertebrae. Fascia is incised. Paravertebral muscles are retracted. The physician removes the spinous processes with rongeurs. The physician removes the lamina out to the articular facets using a burr. A Penfield elevator peels the ligamentum flavum away from the dura. Nerve root canals are freed by additional resection of the facet, and compression is relieved by removal of any bony or tissue overgrowth around the foramen. Removal of the lamina, facets, and bony tissue or overgrowths was performed bilaterally. The rongeur, retractor, and microscope are removed. A free-fat graft is placed over the nerve roots for protection. Paravertebral muscles are repositioned, and the deeper tissues and skin are closed with layered sutures. Missouri Subscriber Answer: This is a surgical laminectomy, which you can report with a pair of codes in this case. On the claim, report 63047 (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; lumbar) for the L4-L5 laminectomy. Then, you’ll report +63048 (… each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)) for the L5-S1 laminectomy. Finally, you’ll append M48.061 (Spinal stenosis, lumbar region without neurogenic claudication) to 63047 and +63048 to represent the patient’s spinal stenosis. Chris Boucher, MS, CPC, Senior Development Editor, AAPC
