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2025 CPT code 63015

Laminectomy with exploration and/or decompression of the spinal cord and/or cauda equina, excluding facetectomy, foraminotomy, or discectomy, involving more than two cervical vertebral segments.

Adhere to the current CPT coding guidelines for spinal surgery.Accurate documentation of the number of vertebral segments decompressed is crucial for proper coding.

Modifiers may apply depending on the circumstances of the procedure (e.g., 51 for multiple procedures, 59 for distinct procedural service, etc.).

Medical necessity for this procedure is established by clinical evidence of significant spinal cord compression or nerve root impingement causing neurological deficits or intractable pain refractory to conservative management.The number of vertebral segments involved must be documented.

The surgeon's responsibility includes removing the spinous processes and laminae of the affected vertebrae, and ensuring decompression of the spinal cord or nerve roots.This requires meticulous surgical technique to avoid neurological injury.

IMPORTANT:63001 (Laminectomy, 1 or 2 cervical segments), 63016 (Laminectomy, more than 2 thoracic segments), 63017 (Laminectomy, more than 2 lumbar segments)

In simple words: This code describes a type of back surgery where the surgeon removes part of the bone surrounding the spinal cord in the neck to relieve pressure on the nerves. This is done on more than two bones in the neck and does not involve removing other parts of the bone.

This CPT code, 63015, signifies a laminectomy procedure performed on more than two cervical vertebral segments.The procedure involves exploration and/or decompression of the spinal cord and/or cauda equina.It specifically excludes facetectomy, foraminotomy, or discectomy. The surgeon removes the spinous process and one or both laminae of the vertebrae to decompress the spinal cord or nerve roots.The extent of the surgery depends on the patient's condition, potentially encompassing multiple adjacent vertebral levels.This procedure is typically indicated for conditions such as spinal stenosis.

Example 1: A 60-year-old patient presents with severe cervical spinal stenosis affecting multiple vertebral segments (C3-C6), causing significant myelopathy.A laminectomy (63015) is performed to decompress the spinal cord., A 55-year-old patient with cervical spondylosis and radiculopathy involving C4-C7 undergoes a laminectomy (63015) to alleviate nerve root compression., A 70-year-old patient with a history of trauma causing cervical spinal cord compression at multiple levels undergoes a laminectomy (63015) for decompression.

Preoperative imaging (X-rays, MRI, CT scan) demonstrating the extent of the stenosis and/or compression. Operative report detailing the specific levels involved and the decompression technique used.Postoperative neurological examination documenting improvement in symptoms.

** This procedure typically involves significant surgical time and skill, making accurate documentation critical for proper reimbursement.

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