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Question: I have an operative report in front of me that is a bit confusing:

CC: Herniated disc L4-L5 with radiculopathy

Physician actions: Lumbar microdiscectomy L4-L5 bilateral

The physician makes a midline incision through a posterior approach overlying the vertebrae. The incision is carried down through the tissue to the paravertebral muscles, which are retracted. The ligamentum flavum is partially removed. Part of the lamina is removed on one side to allow access to the spinal cord. A facetectomy and a foraminotomy are also performed to relieve pressure on the nerve. When decompression is complete, a free-fat graft was placed to protect the nerve root. The remaining portion of the ligamentum flavum is placed over the fat graft. Paravertebral muscles are repositioned and the tissue is closed in layers.  

Can you help me code this encounter?

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Answer: You can report all of the services you described in the above scenario with a single code: 63030 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar).

You’ll also need to consider modifiers, as most payers want you to report these bilateral procedures in one of two ways:

• 63030 with modifier 50 (Bilateral procedure) appended
• 63030 on two separate lines with modifiers LT (Left side) and RT (Right side) appended

Regardless of modifier choice, append M51.16 (Intervertebral disc disorders with radiculopathy, lumbar region) to 63030 to represent the patient’s injury.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC