Spinal Coding: Options for Surgical Lumbar Decompression
By Brittany Kuhlman, COC, CPC, CCC
Surgical lumbar decompression is a procedure that is commonly performed to relieve pressure on the spinal nerves in the lower back. This is typically recommended for individuals who are experiencing chronic back pain, numbness, or weakness due to conditions such as spinal stenosis or a herniated disc. Selecting the correct CPT for these types of procedures is determined not only by the approach but by the diagnosis the patient presents with. In this blog post, we’ll explore the coding options for the lumbar region from a posterior approach. We’ll begin by breaking down the basic mechanics of these procedures before diving deeper into the applicable codes and guidelines.
By its most basic definition, surgical lumbar decompression involves removing bone, disc material, or tissue that is compressing the spinal nerves in the lower back. This procedure is typically recommended for individuals who have not responded to conservative treatments such as physical therapy, medication, or spinal injections.
This procedure can be performed using several techniques, including:
Microdiscectomy: This involves removing a small portion of the herniated disc that is pressing on the nerve root.
Laminectomy: This entails removing the lamina, which is the bony arch that covers the spinal canal, to create more space for the nerves.
Foraminotomy: This means removing bone or tissue from the neural foramen, which is the opening through which the nerve exits the spinal canal.
Osteophyte removal: This is to remove bony overgrowth that is compressing the spinal nerves.
As previously stated, we are going to focus on the more commonly seen posterior approach. This is when the patient is positioned prone (face down), and the surgical approach is made directly on top of the spine itself. The CPT selection for this review will be:
63030: Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar
63047: Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar
At first glance, these codes are remarkably similar. What is being removed from the spine and which diagnosis the patient is being treated for is where the difference between these codes lies. The descriptor for CPT 63030 states that it is for the removal of a herniated disc (HNP) while CPT 63047 is for the decompression of spinal stenosis.
But what if the patient has both spinal stenosis and a disc herniation at the same level?
Per CPT Assistant (May 2020, Vol 30, Issue 5, pg 14), if the initial intent for the surgery was a herniated disc but a decompression (63047) is also performed, they indicate that it is appropriate to report 63047 instead of 63030 regardless of the initial intent for the surgery. When checking NCCI edits, 63030 also bundles into 63047 which aligns with this advice.
What to keep in mind in this instance is our basic ICD-10 guidelines which state that we do not report signs or symptoms when you have a definitive diagnosis. If the spinal stenosis is being caused by the herniated disc, it would be considered a symptom as the treatment of the herniated disc will resolve the incidental stenosis. How to differentiate when the stenosis is incidental to HNP is dependent upon the surgeon’s documentation and your own internal coding policies.
From a coder’s perspective, here is what I keep in mind and look for in these operative reports:
If both stenosis and HNP are listed in the header, what is documented in the body of the report? We do not code by what is in the header, so the body of the report is where we will find our final answers.
Is only bone being removed from the lamina to decompress nerves with no mention of a herniated disc in the body of the report? This would indicate that the primary diagnosis in this instance is stenosis which leads me to CPT 63047.
Is bone removed primarily for access to herniated disc material with limited or no mention of stenosis being decompressed? This would lead me to 63030.
When performing the decompression, does the provider state that the stenosis is incidental? This does occur on occasion which would lead me to follow the ICD-10 guidelines listed above and select 63030 again.
Another situation to be mindful of, is that if the surgeon treats stenosis at one level and then HNP at a distinctly separate level, these two codes can be unbundled. Example: 63047 reported at L4-5 and 63030 at L5-S1 can be unbundled with an appropriate modifier if the clinical indications are properly documented. Like most things in coding, documentation is key. If the operative reports you’re reviewing are entirely unclear which way to go, it may be time to discuss this with your provider via query and firm up your internal coding policies.
So, what if your patient is also undergoing posterior arthrodesis at the same time? In 2022, we saw the additions of the following new add-on CPT codes to address this exact situation:
+63052: Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure)
+63053: Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional vertebral segment (List separately in addition to code for primary procedure)
These add-on codes are to be reported with the following primary procedures: 22630, 22632, 22633, and 22634. According to the parenthetical notes, these codes “may only be reported for decompression at the same anatomic site(s) when posterior interbody fusion (eg, 22630) requires decompression beyond preparation of the interspace(s) for fusion.”
In short, it isn’t advisable to report these add-on codes unless there is sufficient documentation showing additional work was performed by the surgeon to treat stenosis at that same anatomical site. If your posterior arthrodesis is performed for spondylolisthesis and instability, a separate diagnosis of stenosis at the same level would need to be documented in order to support the decision to report these codes.
Parenthetical notes additionally go on to state to not report 63030, 63035, 63047, or 63048 in conjunction with 22630, 22632, 22633, 22634 for laminectomy performed on the same interspaces and vertebral segments as the posterior interbody fusion. Only the above-referenced add-on codes can be reported with these arthrodesis codes for decompression.
Since an interbody arthrodesis requires the removal of material from the disc space and the descriptor of add-on code 63052 aligns largely with CPT 63047, I would hesitate to additionally report these add-on codes for a herniated disc. This is a situation that should be discussed with your providers and coding staff to ensure coding policies are in place to address any gray area for consistent, accurate coding.
For further discussion of these types of procedures, please join us for a complimentary webinar, “Spinal Surgery Review: A CPT Perspective,” on February 28, 2023.
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