Neurosurgery Coding Alert

Question: A neurosurgeon in our group performed a diskectomy with nerve decompression and removed bone spurs at interspaces C3/C4 and C4/C5, followed by fusion at both levels. Can I report both the diskectomy and fusion for more than one level?


New York Subscriber


Answer: Yes. You should first report 63075 (Diskectomy, anterior, with decompression of spinal cord and/or nerve root[s], including osteophytectomy; cervical, single interspace) for diskectomy at the initial interspace and +63076 (... cervical, each additional interspace [list separately in addition to code for primary procedure]) for the second interspace.

Likewise, you should claim 22554 (Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace [other than for decompression]; cervical below C2) for fusion at the first level and +22585 (... each additional interspace [list separately in addition to code for primary procedure]) for fusion at the subsequent level.

Tip: Don't bill separately if the neurosurgeon uses an operating microscope during the diskectomy with decompression. You should not report +69990 (Microsurgical techniques, requiring use of operating microscope [list separately in addition to code for primary procedure]) in addition to 63075-63076. CPT defines use of the operating microscope as an inclusive component of diskectomy.