2025 CPT code 63052
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s)), during posterior interbody arthrodesis, lumbar; single vertebral segment.
Modifiers may be applicable in certain situations, such as if the procedure is reduced in scope (modifier 52), discontinued (modifier 53), or if there are other unusual circumstances (modifier 59).
Medical necessity must be established for both the posterior lumbar interbody fusion and the decompression procedure. This typically involves demonstrating that conservative treatments have failed to alleviate the patient's symptoms and that the procedures are necessary to address the underlying pathology, such as spinal stenosis or nerve root compression causing significant functional impairment.
The surgeon performs the procedure after the patient is prepped and anesthetized. They remove a portion of the vertebral bone (lamina, facet joint, or part of the foramen) to widen the spinal canal and/or neural foramina. This decompresses the spinal cord, cauda equina, and/or nerve roots. The procedure is performed at the same surgical session as a posterior lumbar interbody arthrodesis. The surgeon also performs the necessary steps for the fusion.
In simple words: During a spinal fusion surgery in the lower back, the surgeon sometimes needs to remove some bone to relieve pressure on the spinal cord and nerves. This procedure might involve removing part of the lamina (the bony arch of the vertebra), the facet joint, or widening the openings for the nerves. This code covers such a decompression procedure on one vertebral level, performed at the same time as a posterior interbody fusion in the lumbar spine.
This code reports a laminectomy, facetectomy, or foraminotomy performed during a posterior interbody arthrodesis (spinal fusion) on a single vertebral segment in the lumbar spine. The procedure aims to decompress the spinal cord, cauda equina, and/or nerve roots, often to address stenosis (narrowing of the spinal canal). It can be performed unilaterally (on one side) or bilaterally (on both sides). This is an add-on code and should be reported in addition to the primary procedure code for the interbody arthrodesis.
Example 1: A patient presents with lumbar spinal stenosis and instability at L4-L5. A posterior lumbar interbody fusion is planned. During the fusion procedure, a laminectomy is performed at L4 to decompress the spinal cord and relieve the stenosis., A patient has a herniated disc at L5-S1 with nerve root compression, alongside segmental instability. The surgeon performs a posterior lumbar interbody fusion at L5-S1 and a foraminotomy at L5 to decompress the affected nerve root during the same session., A patient with degenerative spondylolisthesis and spinal stenosis requires a posterior interbody fusion at L3-L4. A bilateral facetectomy is performed at L3 during the fusion to decompress the spinal cord and nerve roots and address the stenosis.
Documentation should include the diagnosis necessitating both the fusion and the decompression procedure (e.g., spinal stenosis, herniated disc, instability). Operative reports should detail the specific type of decompression performed (laminectomy, facetectomy, or foraminotomy), the level(s) at which it was performed (single level for 63052), whether it was unilateral or bilateral, and confirmation that it was performed during the same session as the posterior lumbar interbody arthrodesis.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center