Neurosurgery Coding Alert

Question: Encounter notes indicate that the surgeon performed “DREZ laminectomy, thoracolum.” I don’t know what this term means, or how to code this procedure; could you help?

Louisiana Subscriber

Answer: You should check with the surgeon before coding if possible, but these notes seem to indicate that the surgeon performed a thoracolumbar laminectomy with myelotomy, which you’d report with 63170 (Laminectomy with myelotomy (eg, Bischof or DREZ type), cervical, thoracic, or thoracolumbar).

Explanation: DREZ stands for dorsal root entry zone, which is where the surgeon accesses the spine via laminectomy for a DREZ type procedure. As the descriptor for 63170 reads, you should report this code if the patient undergoes a “DREZ type” laminectomy. You’d also report 63170 if the notes indicate that the surgeon performs a Bischof-type laminectomy. Check the documentation to see if microdissection was performed with the operating microscope as you may additionally be able to report CPT^® 69990.