Neurosurgery Coding Alert

Question: Our surgeon performed "L4-5 foraminotomy and removal of synovial cyst." The cyst was adhered to the dura, and the surgeon allowed a portion of the cyst to remain to prevent dural tear. How should I code this? Nebraska Subscriber Answer: From the description you provide, your surgeon likely performed medial facetectomy and foraminotomy, in addition to excision, to treat a degenerative process that typically causes lateral recess compression. The actual physician work of synovial cyst excision is quite similar to that of 63030 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, lumbar [including open or endoscopically-assisted approach]), although without the discectomy. The procedure also closely resembles a unilateral laminectomy, 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, caudal equine and/or nerve root(s) (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar). Your third option is 63267 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar). Although you could argue in favor of any of these choices, the synovial cyst represents excision of an extradural lesion, making 63267 the best fit from a coding perspective. Don't be surprised if your surgeon argues, however, that either 63030 or 63047 better represents the actual work involved.