Neurosurgery Coding Alert

Question: Our surgeon performed a laminectomy with bilateral foraminotomies with decompression of the spinal cord/nerve roots for severe stenosis. The surgeon argues that we should report this using 63047, but I disagree because the operative note does not mention facetectomy, which is included in 63047. How should I report this? What about 63047-52?

California Subscriber

Answer: This may be more a documentation issue than a coding problem. Even so, you should probably choose 63047 (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; lumbar) without modifier -52 (Reduced services).

At least a partial or medial facetectomy is a required part of foraminotomy, even if the surgeon did not include it in the operative note. Although you should never assume that the surgeon has done something he has not listed, in this case you may wish to communicate with the surgeon to be sure that the operative note fully describes the procedure.