Subject: Laminotomy (Hemilaminectomy) with Decompression of Nerve Root(s), Including Partial Facetectomy, Foraminotomy and/or Excision of Herniated Intervertebral Disc, Reexploration, Single Interspace-Lumbar with Arthrodesis, Posterior Interbody Technique, Including Laminectomy and/or Discectomy to Prepare Interspace (Other than for Decompression, Single Interspace-Lumbar or Discectomy, Anterior, with Decompression of Spinal Cord and/or Nerve Root(s) with Arthrodesis, Anterior Interbody Technique, Including Minimal Discectomy to Prepare Interspace: Cervical Edit# 577 Effective: 08/17/2007 12/31/2013 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Description CODE RULE CODE 63042 Separate Reimbursement 22630 63042-50 Separate Reimbursement 22630 63042-LT Separate Reimbursement 22630 63042-RT Separate Reimbursement 22630 63047 Incidental 22630 63048 63075 63076 Separate Reimbursement 22554 Rationale Anthem Central Region does not bundle 63042 with 22630, does not bundle 63042-50 with 22630, does not bundle 63042-LT with 22630 and does not bundle 63047-RT with 22630. Based on the Complete Global Service Data for Orthopaedic Surgery, CPT Code 22630, code 63042 is not listed as a service that is included when performing 22630. Based on the National Correct Coding Initiative Edits, code 63042 is not listed as a component code to code 22630. Therefore, if 63042 is submitted with 22630 both services reimburse separately, if 63042-50 is submitted with 22630 both services reimburse separately, if 63042-LT is submitted with 22630 both reimburse separately and if 63042-RT is submitted with 22630 both services reimburse separately. Anthem Central Region bundles 63047 and 63048+ as incidental with 22630. Based on the Complete Global Service Data for Orthopaedic Surgery, CPT code 22630, code 63047 is listed as a service that is included when performing 22630. Based on the National Correct Coding Initiative Edits, code 63047 is listed as a component code to code 22630. Since 63048 is an add on code that only may be reported along with 63047, 63048 follows the same rationale that is used with 63047. Therefore, if 63047 and Central Region Claim Edit#577 Page 1 of 5
63048+ are submitted with 22630 only 22630 reimburses Anthem Central Region does not bundle 63075 with 22554. Based on CPT Assistant article: To report code 22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); cervical below C2, in addition to code 63075-51, Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace, the surgeon must have performed additional procedure(s) and work that leads to the decompression of neural elements. In most cases, the dura and/or neural elements are exposed to ensure decompression which, for reporting purposes, is considered over and above the work described by code 22554. Therefore, in this instance, the decompression procedure 63075 (with the modifier -51 appended) would be reported in addition to code 22554. Examples of types of additional procedures include drilling off the posterior osteophytes using the operating microscope, opening the posterior longitudinal ligament to look for free disk fragments (decompressing the spinal cord), or removing far lateral disk fragments to decompress the nerve roots. Based on the Complete Global Service Data for Orthopaedic Surgeons, code 22554 is listed as a service that is not included when performing CPT code 63075 or add-on code 63076+. Based on the National Correct Coding Initiative Edits, code 63075 is not listed as a component code to code 22554. Since 63076 is an add-on code that is to be used along with 63075 the rationale for 63076 is the same as the rationale used for 63075. Therefore, if 63075 is submitted with 22554 both services reimburse separately and if 63075 and 63076+ are submitted with 22554 all services reimburse separately. Reference 1.American Academy of Orthopaedic Surgeons. CPT Code: 22630. Complete Global Service Data for Orthopaedic Surgery. 2007: pg 201 2. American Academy of Orthopaedic Surgeons. CPT code 22554. Complete Global Service Data for Orthopaedic Surgery. 2007: page 191 3. Centers for Medicare and Medicaid (July 1, 2007-September 30, 2007) National Correct Coding Initiative Edits-Version 13.2. Retrieved July 5, 2007 from the World Wide Web: http://www.cms.hhs.gov/nationalcorrectcodinited/ncciep/itemdetail.asp?filtertype=none&f ilterbydid=- 99&sortByDID=2&sortOrder=ascending&itemID=CMS046542&intNumPerPage=10 4. American Medical Association. Coding Consultation-Nervous System, 63040, 63042, 63047 (Q&A). CPT Assistant, 1999: 9(1): 12 Central Region Claim Edit#577 Page 2 of 5
Subject: Laminotomy (Hemilaminectomy) with Decompression of Nerve Root(s), Including Partial Facetectomy, Foraminotomy and/or Excision of Herniated Intervertebral Disc, Reexploration, Single Interspace-Lumbar with Arthrodesis, Posterior Interbody Technique, Including Laminectomy and/or Discectomy to Prepare Interspace (Other than for Decompression, Single Interspace-Lumbar or Discectomy, Anterior, with Decompression of Spinal Cord and/or Nerve Root(s) with Arthrodesis, Anterior Interbody Technique, Including Minimal Discectomy to Prepare Interspace: Cervical Edit# 577 Effective: 05/25/2007 08/16/2007 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and the edit criteria listed below. Please compare the claim's date of adjudication to the range of the edit in question. Prior versions, if any, can be found below. Description CODE RULE CODE 63042 Incidental 22630 63042-59 Separate Reimbursement 22630 63047 Incidental 22630 63048 63047-59 Separate Reimbursement 22630 63048-59 63075 Incidental 22554 63076 63075-59 63076-59 Separate Reimbursement 22554 Rationale Anthem Central Region bundles 63042 with 22630, does not bundle 63042-59 with 22630. Based on CPT Assistant article: Coding Consultation, Musculoskeletal System, Surgery, 22554, 22630, 63001-63048, 63075-63078 (Q&A): Question The descriptors of codes 22554 and 22630 describe anterior (22554) or posterior (22630) interbody technique arthrodeses to include laminectomy, and/or discectomy to prepare the interspace (other than for decompression). In what procedural circumstance would the 63001-63048 code(s) be reported in addition to code 22630? Similarly, in what procedural circumstance would code(s) 63075-63078 be reported in addition to code 22554? AMA Comment For both codes 22554 and 22630, if the surgeon is removing disk and/or bony endplate solely with the need to prepare the vertebrae for fusion; then no additional 63000 series code(s) is Central Region Claim Edit#577 Page 3 of 5
reported. The appropriate 63045-63048, 63075-63078 code(s) should be reported, when in addition to removing the disk and preparing the vertebral endplate, the surgeon removes posterior osteophytes and decompresses the spinal cord or nerve root(s), which requires work in excess of that normally performed when doing a posterior lumbar interbody fusion (PLIF). Based on a second CPT Assistant article, Coding Consultation, Nervous System, 63040, 63042, 63047 (Q&A) Question My physician performs reexploration of L4-5, and then goes up or down a level to perform a laminectomy at a new level that has not been operated on in the past. What are the appropriate codes for this procedure? AMA Comment From a CPT coding perspective, it is appropriate to report CPT code 63042 to describe the procedure where a laminotomy is performed while concurrently performing nerve root decompression, partial facetectomy, foraminotomy, and/or excision of herniated intervertebral disk with reexploration at the lumbar level. CPT code 63040 and subsequent indented code 63042are the only codes which may be reported for procedures performed on a recurrent herniated nucleus pulposus. If a laminectomy, facetectomy, and foraminotomy are performed concurrently, unilaterally or bilaterally, with decompression of the spinal cord, cauda equina and/or nerve roots, on a single vertebral segment (not interspace) at the lumbar level, and this segment has not been previously explored, then it would be appropriate to report CPT code 63047. CPT code 63048 is an add-on code which may be reported only when 63047 has been reported for the first lumbar vertebral segment procedure, and it is necessary to report procedures for one or more additional segments. 63042 is a code that is not listed as an appropriate procedure (63040-63048, 63075-63078) that would normally be submitted with 22630. Based on another CPT Article 63040 & 63042 are for recurrent herniated nucleus pulposus. If 63040 and 63042 are being performed for a recurrent herniated pulposus, append modifier 59 to 63040 and 63042. Therefore, if 63042 is submitted with 22630 only 22630 reimburses, but if 63040-59 and 63042-59 is submitted with 22630 all services reimburse separately. Anthem Central Region bundles 63047 and 63048 as incidental with 22630. Based on CPT Assistant article, listed above, 63047 and 63048 is for the lumbar area are not appropriate to submit if the surgeon is removing disk and/or bony endplate solely with the need to prepare the vertebrae for fusion. Therefore, if 63047 and 63048 is submitted with 22630 only 22630 reimburse. Anthem Central Region does not bundle 63047-59 and 63048-59 with 22630. Based on CPT Assistant article, listed above, if 63047 and 63048 was being performed to remove posterior osteophytes and decompression of the spinal cord or nerve root(s), then append modifier 59 to 63047 and 63048 and both 22630 and 63047 and 63048 reimburse separately. Anthem Central Region bundles 63075 and 63076 as incidental with 22554. Based on CPT Assistant Central Region Claim Edit#577 Page 4 of 5
Reference article listed above, For both codes 22554 and 22630, if the surgeon is removing disk and/or bony endplates solely with the need to prepare the vertebrae for fusion; then no additional 63000 series code(s) is reported Therefore, if 63075 and 63076 is submitted with 22554 only 22554 reimburses. Anthem Central Region does not bundle 63075-59 and 63076-59 with 22554. Based on CPT Assistant article: To report code 22554, Arthrodesis, anterior interbody technique, including minimal diskectomy to prepare interspace (other than for decompression); cervical below C2, in addition to code 63075-51, Diskectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace, the surgeon must have performed additional procedure(s) and work that leads to the decompression of neural elements. In most cases, the dura and/or neural elements are exposed to ensure decompression which, for reporting purposes, is considered over and above the work described by code 22554. Therefore, in this instance, the decompression procedure 63075 (with the modifier -51 appended) would be reported in addition to code 22554. Examples of types of additional procedures include drilling off the posterior osteophytes using the operating microscope, opening the posterior longitudinal ligament to look for free disk fragments (decompressing the spinal cord), or removing far lateral disk fragments to decompress the nerve roots. 1. American Medical Association. Coding Consultation-Musculoskeletal System, Surgery, 22554, 22630, 63001-63048, 63075-63078 (Q&A). CPT Assistant, 2001; 1(12): 12 2. American Medical Association. Coding Consultation-Nervous System, 63040, 63042, 63047 (Q&A). CPT Assistant, 1999; 9(1): 12 Claim Edit History 01/01/2014 Archived: Following NCCI 08/16/2007 Edited 05/25/2007 Adopted Central Region Claim Edit#577 Page 5 of 5