Basics of CPT code 63045, 63046, 63047, 63048

The procedure described these CPT codes involves a laminectomy, a surgical procedure that involves the removal of the spinous process and one or both lamina of a vertebra. The purpose of this surgery is to alleviate pressure on the spinal nerves and treat conditions such as spinal stenosis, herniated discs, or tumors. During the laminectomy, the surgeon targets the affected vertebra and carefully removes the necessary bony structures to create more space in the spinal canal. This allows for the decompression of the nerves, which in turn relieves pain, numbness, and other symptoms caused by the underlying condition. Today , we will learn about coding  rules for CPT code 63045, 63046, 63047, 63048 for laminectomy, facetectomy, and foraminotomy.

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Description of CPT code 63045, 63046, 63047, 63048

The physician performs a unilateral or bilateral laminectomy, facetectomy, or foraminotomy of a vertebral segment with decompression of the spinal cord, cauda equina, and/or nerve roots to treat conditions such as spinal or lateral recess stenosis. The patient is face down. Magnification may be used during the procedure. The physician makes a midline incision overlying the affected vertebrae. Fascia is incised. Paravertebral muscles are retracted. The physician removes the spinous processes with rongeurs. If the stenosis is central, the physician removes the lamina out to the articular facets using a burr. If the compression is in the lateral recess, only half of the lamina is removed. A Penfield elevator peels the ligamentum flavum 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. The rongeur, retractor, and microscope are removed. A free-fat graft may be placed over the nerve root(s) for protection. If the ligamentum flavum was spared, it is placed over the free-fat graft. Paravertebral muscles are repositioned and the deeper tissues and skin are closed with layered sutures.

CPT code 63045 is reported when this procedure is a single cervical vertebral laminectomy, facetectomy, and foraminotomy.

CPT code 63046 is reported if the procedure affects a thoracic vertebra report

This procedure is a single thoracic vertebral laminectomy, facetectomy, and foraminotomy.

CPT code 63047 is reported  if the procedure affects a lumbar vertebra

The provider performs a laminectomy (excision of the thin bony plate at the back of a vertebra), facetectomy (excision of an area of a vertebra characterized by its smooth surface), and foraminotomy (incision into the vertebral opening through which nerve bundles exit out to the body) at a single lumbar vertebral segment to correct spinal stenosis (narrowing) and decompress the spinal cord or nerve roots.

CPT code 63048 is assigned for procedures affecting each additional vertebral segment.

At the same session as laminectomy, facetectomy, and foraminotomy on an initial segment for decompression, the provider performs the procedure on an additional vertebral segment.

63045 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; Cervical

63046 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; thoracic

63047 Laminectomy facetectomy, and foraminotomy (unilateral of bilateral with decompression of spinal cord, cauda equine and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; lumbar

63048 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; each additional vertebral segment, cervical, thoracic, or lumbar

(List separately in addition to code for primary procedure)