Neurosurgery Coding Alert

Question: An established patient with lumbar stenosis reports to the surgeon. After a level-three E/M service, the surgeon performs a spinal canal decompression on the same day. During the procedure, the surgeon removes left lamina from the second lumbar vertebrae, then removes spinous process and right lamina from the third lumbar vertebrae. Do I need any modifiers for this encounter -- either 50 for the decompression or 25 for the E/M?

Indiana Subscriber Answer: You will not need help from modifier 50 (Bilateral procedure) in this scenario because you will report the same codes for spinal decompression whether the procedure is lateral or bilateral.

But you will need to include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on this claim to show the insurer that the E/M and the decompression were separate services.

On your claim, submit the following:

- 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) for the L2 decompression

- +63048 (- each additional segment, cervical, thoracic or lumbar [list separately in addition to code for primary procedure]) for the L3 decompression

- 724.02 (Spinal stenosis, lumbar region) linked to 63047 and 63048 to represent the patient's stenosis

- 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity) for the E/M service

- 724.02 linked to 99213 to represent the patient's stenosis

- modifier 25 attached to 99213 to show that the E/M was separate from the decompression.