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2025 CPT code 63086

Anterior or anterolateral approach for extradural exploration/decompression procedures on the spine and spinal cord; thoracic, each additional segment.

Adhere to all CPT coding guidelines for surgical procedures on the nervous system.Pay close attention to the definition of "additional segment" and properly code for each level of vertebral involvement. Modifier 62 is used when two surgeons work together as primary surgeons each performing distinct parts of the operation.Use of modifier 62 will require additional documentation.

Modifiers 50, 51, 52, 59, and 62 may apply depending on the circumstances of the procedure.

Medical necessity is established through thorough clinical documentation demonstrating significant spinal cord compression or stenosis leading to neurological deficits.The documentation should show that conservative treatment options have failed and that surgical intervention is necessary to improve neurological function.

The surgeon's responsibility includes the planning and execution of the surgical procedure, including incision, bone resection, decompression of the spinal cord and nerves, and reconstruction of the vertebral column as needed.This requires expertise in spinal surgery and thoracic surgery.

IMPORTANT:This code is often used in conjunction with 63085 (initial segment) and may require modifier 62 if performed by a second surgeon concurrently working on a distinct part of the operation. Additional codes may be needed to reflect instrumentation and bone grafting procedures.

In simple words: The doctor removes part or all of a bone in the upper back (thoracic spine) through an incision in the chest to relieve pressure on the spinal cord and nerves.This code is used for each additional bone segment removed after the first one.

This CPT code, 63086, represents the performance of an anterior or anterolateral approach for extradural exploration and decompression procedures on the spine and spinal cord, specifically targeting each additional thoracic segment.It involves a transthoracic approach to resect additional vertebral segments, encompassing decompression of the spinal cord and/or nerve roots. This procedure is typically performed after an initial excision of a thoracic vertebra. The procedure includes opening the thoracic cavity, removing the diseased vertebral bone segment, decompressing the affected spinal cord and nerve roots, and potentially including the removal of adjacent intervertebral discs, followed by reconstruction of the vertebral column with bone grafts and possible instrumentation (plates, screws etc.). This code is reported in addition to the primary procedure code.

Example 1: A patient presents with severe spinal stenosis at the T4-T5 and T5-T6 levels due to degenerative disc disease and osteophyte formation.The surgeon performs a corpectomy at T5 and requires decompression and stabilization across three levels.63085 would be used for T5, and 63086 would be used once for T4 and once for T6., A patient experiences significant spinal cord compression from a tumor at T3, T4, and T5.The surgeon completes a three-level corpectomy and decompression, requiring the use of 63085 for the primary level (e.g., T4) and 63086 twice for T3 and T5, along with other codes for instrumentation and bone grafting., Two surgeons work collaboratively to perform a complex thoracic corpectomy.One surgeon focuses on the anterior approach and decompression, while another handles instrumentation and stabilization.Both surgeons would likely use modifier 62 with 63085 and/or 63086 to indicate their individual contributions.

Detailed operative report specifying the approach (anterior/anterolateral), the levels involved, specific details about the decompression procedure (e.g., extent of bone removed, nerve root involvement), the reconstruction methods (bone graft type and volume, instrumentation used), and any intraoperative complications or findings.Preoperative imaging (CT, MRI) demonstrating the spinal stenosis or other pathology necessitating surgery.Postoperative imaging to document the surgical outcome.Complete anesthesia record.

** This code is for add-on services only and must be reported in conjunction with a primary procedure code for a thoracic corpectomy or similar procedure.The number of 63086 codes reported should correspond to the number of additional segments involved beyond the initial segment.

  • Payment Status: Active
  • Modifier TC rule: Not applicable; this is not a procedure that commonly uses a TC modifier.
  • Specialties:Neurosurgery, Orthopedic Surgery
  • Place of Service:Inpatient Hospital, Ambulatory Surgical Center
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