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The following article is written by Stephanie Ellis, RN, CPC, president of Ellis Medical Consulting.
When the laminectomy/laminotomy is performed primarily for herniated discs and the decompression procedure is not the primary reason, CPT codes 63020/63030 are used. When the laminectomy/laminotomy is performed primarily for spinal stenosis, the decompression procedure is the primary focus and only a minor (or none) discectomy is performed in the procedure, these codes would be used.
Use CPT 63045 for cervical or CPT 63047 for lumbar, with additional levels billed with add-on code +63048 inilateral or bilateral. In this procedure, the physician removes the spinous process.
If the stenosis is central, the lamina may be removed out to the articular facets using a burr. If the compression is in the lateral recess, only half of the lamina is removed. The ligamentum flavum is peeled away from the dura. Nerve root canals are freed by additional resection of the facet, and compression is relieved by removal of any bony or tissue overgrowth around the foramen. Removal of the lamina, facets and bony tissue or overgrowths may be performed bilaterally, when indicated. Do not use the -RT, -LT or -50 modifiers with these codes.
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The information provided should be utilized for educational purposes only. Please consult with your billing and coding expert. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
Related Articles on Spine Coding:
Surgery Center Coding Guidance: Redo Laminotomy or Laminectomy Procedures
Surgery Center Coding Guidance: Total Disc Arthroplasty Procedures
Surgery Center Coding Guidance: X-Stop Procedure