2025 CPT code 63078
(Active) Effective Date: N/A Revision Date: N/A Surgery - Spinal Cord Procedures Surgical Procedures on the Nervous System Feed
Each additional thoracic interspace in an anterior or anterolateral approach for extradural exploration/decompression procedures on the spine and spinal cord.
Modifiers 51 (multiple procedures), 59 (distinct procedural service), and 62 (two surgeons) may be applicable depending on the specific circumstances of the surgical procedure.Refer to CPT guidelines for specific modifier usage.
Medical necessity for this procedure is established by the presence of symptomatic thoracic disc herniations causing significant neurological compromise or pain refractory to conservative management (e.g., physical therapy, medication).Documentation should clearly demonstrate the need for surgical intervention based on the patient's clinical presentation, response to conservative treatment, and the potential for improved neurological function or pain relief.
The clinical responsibility lies with the surgeon performing the anterior or anterolateral approach for extradural exploration/decompression procedures. This involves accessing, removing herniated disc material, preparing vertebral bodies for grafts (if necessary), inserting grafts, suturing, closing the incision, and potentially placing a chest drain. Postoperative care is also under the surgeon's responsibility.
- Surgical Procedures on the Nervous System
- Surgical Procedures on the Nervous System > Spinal Cord Procedures
In simple words: This code is for extra work done by a surgeon during the same spinal surgery.If the surgeon has to fix more than one problem area in the spine's thoracic region (mid-back), this code covers each area after the first. This means one code (63077) will be used to bill the first problem, and this code (63078) is added for every additional problem fixed.
This CPT code, 63078, represents each additional thoracic interspace addressed during an anterior or anterolateral approach for extradural exploration and decompression procedures of the spine and spinal cord.It is an add-on code and must be used in conjunction with the primary procedure code (63077) for the initial interspace.The procedure involves accessing and removing herniated disc material to decompress the spinal cord and nerve roots. Bone grafts may be used to fill the space created by disc removal.This code is reported for each additional interspace beyond the first, accessed during the same operative session.
Example 1: A patient presents with thoracic disc herniations at T4-T5 and T5-T6.The surgeon performs an anterior approach, removing the herniated disc at T4-T5 (63077). The additional herniation at T5-T6 is then addressed, requiring 63078., A patient with multiple thoracic disc herniations undergoes an anterior approach.The surgeon decompresses three interspaces during the same surgical session.The billing would consist of 63077 for the primary interspace, and two units of 63078 for each subsequent interspace., During an anterior approach for a primary thoracic discectomy, the surgeon encounters and addresses an unexpected additional herniated disc at an adjacent interspace.Both disc herniations are resolved in the same surgical session. 63077 would be billed for the primary disc and 63078 for the additional interspace.
* Preoperative diagnosis clearly indicating the location and number of affected thoracic interspaces.* Operative report detailing the approach, techniques used, specific interspaces addressed, and any complications encountered.* Anesthesia record.* Pathology report (if applicable).* Imaging studies (e.g., MRI, CT scan) showing the extent of the disc herniations.
** This code is only reported for additional thoracic interspaces beyond the initial interspace, billed with code 63077.Accurate documentation is critical to ensure appropriate reimbursement. Always consult the latest CPT manual for updates and clarifications.
- Revenue Code: P1F (MAJOR PROCEDURE - EXPLOR/DECOMPR/EXCISDISC)
- RVU: The relative value units (RVUs) for this code will vary depending on the geographic location, facility type (inpatient vs. outpatient), and other factors. Consult the appropriate fee schedule for specific RVU values.
- Global Days: The global period for this procedure is dependent upon the primary procedure code used in conjunction with 63078 and other applicable factors.Consult the specific guidelines and fee schedules for further clarification.
- Payment Status: Active
- Modifier TC rule: Not applicable. This is an add-on code.
- Fee Schedule: Historical fee schedule data is not available here. Consult a reliable medical billing resource for historical fee schedules data.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center