2025 CPT code 63056
Effective Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach).
Modifiers, such as 22 (increased procedural services), 59 (distinct procedural service), and 62 (two surgeons) may be applicable depending on the circumstances of the procedure.
Medical necessity is established by documentation of symptoms, signs, and diagnostic studies that confirm nerve root compression or spinal stenosis, along with failed conservative treatment options.
The surgeon makes a small incision in the lower back and uses specialized tools to carefully access the spine through a small opening in the bone (pedicle). Visualization is often aided with fluoroscopy or an operating microscope. The surgeon removes a portion of the herniated disc material to relieve the pressure on the spinal nerves. Bone graft material may be used to fill the defect and help stabilize the spine. The muscles and tissues are then carefully closed, and a sterile dressing applied.
In simple words: This procedure relieves pressure on the spinal cord or nerves in the lower back. The surgeon goes through the side of a back bone to reach the affected disc. This helps relieve pain and other symptoms caused by pressure on the nerves.
This code describes a surgical procedure performed to decompress the spinal cord, equina, or nerve roots in the lumbar region using a transpedicular approach. This approach involves accessing the spine through the pedicle of the vertebra. The procedure is often performed to treat conditions such as a herniated intervertebral disc. This code also includes transfacet or lateral extraforaminal approaches, which may be used for far lateral herniated discs.
Example 1: A patient presents with severe lower back pain and leg pain radiating down the right leg, diagnosed as a herniated disc at L4-L5 causing nerve root compression. A transpedicular approach is used to access and remove the herniated disc fragment, relieving pressure on the nerve root., A patient experiencing lower back pain and numbness in both legs is diagnosed with spinal stenosis at the L5 level. A transpedicular approach with complete facetectomy allows the surgeon to decompress the affected nerve roots and relieve the stenosis., A patient with a far lateral herniated disc at L3-L4 experiences debilitating pain. The surgeon performs a transpedicular approach, incorporating a lateral extraforaminal approach to access and remove the herniated portion of the disc without disturbing the spinal cord.
Documentation should include the diagnosis, the specific level of the spine affected, the surgical approach used (transpedicular, transfacet, or lateral extraforaminal), the extent of the decompression, any associated procedures performed (e.g., facetectomy), and the use of bone graft, if applicable.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center