Medical Coding for Laminectomy – A Common Orthopedic Surgical Procedure

Medical Coding for Laminectomy – A Common Orthopedic Surgical Procedure

Laminectomy is a surgical procedure that removes the lamina - the back part of a vertebra that covers your spinal canal. Read the article to know more about the procedure

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If you happen to experience mild to severe back pain that generally spreads down to your legs, then it must be a symptom of spinal stenosis. Spinal stenosis is caused by the narrowing of the spaces within the spinal column which puts pressure on the spinal cord or nerves. The condition generally occurs due to the wear and tear changes in the spine and other causes including herniated disks, thickened ligaments, overgrowth of bone, tumors and spinal injuries. This spinal disorder is most common in men and women above 50 years of age. However, it can also occur in younger people who are born with a narrowing of the spinal canal or who suffer an injury to the spine. In some cases, the narrowing of the spinal column may heal with conservative modalities like practicing proper body mechanics, back exercises, anti-inflammatory medications and physical therapy. However, in most cases, long-lasting pain relief can be easily achieved through a surgical procedure known as a “laminectomy”. Laminectomy is a surgical procedure wherein a surgeon removes part or all of the vertebral bone (lamina – the back part of a vertebra that covers your spinal canal). This helps ease pressure on the spinal cord or the nerve roots that may be caused by injury, herniated disk, narrowing of the canal (spinal stenosis), or tumors. A laminectomy is considered only after other medical treatments have not worked. Orthopedic surgeons who perform this procedure need to correctly document the same in the patient’s medical records. Opting for billing and coding services from a reputable medical billing and coding outsourcing company can help simplify the documentation process.

Also known as decompression/lumbar surgery, laminectomy is generally performed in the cervical and lumbar regions, and less often in the thoracic region. Bony overgrowths within the spinal canal can narrow the space available for your spinal cord and nerves. This pressure can cause pain, weakness or numbness that can radiate down your arms or legs. Generally, laminectomy is considered a safe procedure. However, as with any type of surgery, this also involves its own risk of complications and these include – bleeding, infection, blood clots, nerve injury and spinal fluid leak.

How Is Laminectomy Performed?

Before undergoing the surgical procedure, patients need to provide a complete medical history to the physicians. This may include information about any prescription or over-the-counter drugs, vitamins, or supplements consumed, allergic reactions to any medications, anesthetic agents, tape, or www.outsourcestrategies.com

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latex and pregnancy issues (if any). Before the surgery, the physician may ask patients to stop consuming blood thinners, (such as aspirin) and stop the habit of smoking (if he/she is a smoker). In addition, patients may also be asked not to eat or drink anything after midnight the evening before the surgery.

Generally, a laminectomy is performed under general anesthesia. The surgeon will make a small incision or cut in the middle of your back or neck over the affected vertebrae and move the muscles, skin and ligaments away from your spine (as needed) to get a better view. The size of the incision may vary depending on your condition and body size. In most cases, minimally invasive surgeries typically use smaller incisions than those used for open procedures. The surgeon may remove the bony arch of the posterior part of the vertebra (lamina) to ease the pressure on the nerves in the area. This may involve removing bone spurs or growths, or removing all or part of a disk.

However, if one vertebra has slipped over another or if the spine suffers a curvature, spinal fusion may be necessary to stabilize the spine. During a spinal fusion, the surgeon will connect two or more bones in your spine using bone grafts and, if necessary, metal rods and screws. In addition, the surgeon may also perform a foraminotomy to widen the area where the nerve roots go through the spine. The whole process of laminectony takes about 1-3 hours. The incisions will be closed with stitches or surgical staples and a sterile bandage or dressing will be applied.

Removal of either the part or all of the vertebral bone (lamina) is one of the many procedures that a medical coding and billing company helps orthopedic surgeons document, code and report. Orthopedic medical billing and coding is complex as there are several code categories. Orthopedic specialists performing laminectomy must use the relevant medical codes to bill for the procedure.

The CPT codes used to report laminectomy procedure include – 

63001 - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; cervical

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63003 - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; thoracic 63005 - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; lumbar, except for spondylolisthesis 63015 - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; cervical 63016 - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; thoracic 63017 - Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (e.g., spinal stenosis), more than 2 vertebral segments; lumbar 63020 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, cervical 63035 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; each additional interspace, cervical or lumbar (List separately in addition to code for primary procedure) 63040 - Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical 63045 - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., 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], [e.g., spinal or lateral recess stenosis]), single vertebral segment; thoracic

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63048 - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [e.g., spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure)

After the surgery, the patient will be directly shifted to a recovery room wherein they will be closely monitored for any specific complications from the surgery and anesthesia. Patients will be given pain medications and antibiotics to reduce pain at the incision site. They will be asked to slowly lift and move their arms and legs. In some cases, physicians may recommend physical therapy after a laminectomy to improve strength and flexibility.

Depending on the amount of lifting and walking, patients will be able to return to work within a few weeks. However, the recovery time will be longer for patients who had spinal fusion procedure.

Most people may experience visible improvement in their symptoms after laminectomy, particularly a decrease in pain that radiates down the leg or arm. However, the procedure does not prevent the occurrence of spine problems in the future. People who have undergone the procedure need to take essential preventive steps such as avoiding strenuous activities, heavy lifting, be careful while climbing stairs and gradually increase the level of activities like walking as these will prevent the risk of infections.

Knowing the correct medical codes related to laminectomy is critical for providers. Partnering with an experienced medical billing and coding company is a great option for physicians to ensure accurate and timely claim submissions.

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