Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon performed a hemilaminectomy at C1-C2 and C2-C3. The procedure included decompression of nerve roots, foraminotomy, and a reexploration at both interspaces. How should I report this encounter?

Answer: You should report 63040 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated

intervertebral disc, reexploration, single interspace; cervical) for the hemilaminectomy at C1-C2. For the C2-C3 surgery, opt for +63043 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional cervical interspace (List separately in addition to code for primary procedure)).

Remember: You can use the codes above for cervical hemilaminectomies and additional cervical vertebral interspaces. If the surgeon performed the same hemilaminectomy on lumbar interspaces, you’d instead opt for 63042 (… lumbar) and +63044 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure)).