Neurosurgery Coding Alert

Question: The patient had a herniated disc L4-L5 with radiculopathy. The surgeon made a midline incision is made through a posterior (back) approach overlying the vertebrae. The incision was carried down through the tissue to the paravertebral muscles, which were retracted. The surgeon completely removed the ligamentum flavum. Then the surgeon removed part of the lamina on one side to allow access to the spinal cord. A disc had ruptured, so the surgeon removed the fragments of the disc compressing the nerves. The surgeon also performed a facetectomy to relieve pressure on the nerve. Once the decompression was complete, the surgeon placed a free-fat graft to protect the nerve root. Finally, the surgeon repositioned the paravertebral muscles and closed the tissues in layers. Which codes should I report on this claim?

Mississippi Subscriber

Answer: For the CPT^® code on this claim, you should report 63030 (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar), potentially with modifier LT (Left side) or RT (Right side), depending on the payer.

For the ICD-10 code, you should append M51.16 (Intervertebral disc disorders with radiculopathy, lumbar region) to 63030 to represent the patient’s condition.

The facetectomy and graft placement are not separately reportable. If microdissection was performed, CPT^® allows separate reporting of code +69990 (Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)), though CMS considers this bundled. A fat graft would be separately reportable only if harvested from a separate incision, which would not be typical.