AHA Coding Clinic® for HCPCS - 2021 Issue 3; Ask the Editor

Spinal decompression

A patient with lumbar spondylosis, stenosis and radiculopathy presented for a laminectomy with decompression of the thecal sac and nerve roots at L2, L3 and L4 via both a posterior and transpedicular approach. The patient was placed prone and a linear incision was made. The spinous processes and lamina of L2 through L4 were removed in addition to the removal of degenerated tissue at the L2-L3 disk space. At this point decompression of the thecal sac and nerve roots was completed. Next, additional decompression was performed via a transpendicular approach allowing complete unroofing of the left L3 and L4 nerve roots. Is it appropriate to report both CPT codes 63030, Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar, and 63056, Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc), for the decompression via posterior and transpendicular approaches? ...

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