You Be the Coder:
Check for Neoplasm When Reporting 63270, 63275
Published on Fri Feb 13, 2009
Question: My doctor states he did hemilaminectomy with resection of extradural mass located at C7-T1. Can you help me figure out the correct code to use? Pennsylvania Subscriber Answer: The answer depends on the type of mass the doctor operated on. If the mass was a neoplasm, you should report 63275 (Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical). If it was not a neoplasm, look at code 63265 (Laminectomy for excision of intraspinal lesion other than neoplasm, extradural; cervical). For example, this is the code you would report for excision of a synovial cyst. You should submit the diagnosis and the procedure codes via a pathology report, in case of audit. Catch: Be cautious of the lesion's location. If most of the lesion was in the thoracic spine, you should choose the appropriate thoracic codes instead -- such as, 63276 (- extradural, thoracic) or 63266 (-thoracic).
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