2025 CPT code 63088
(Active) Effective Date: N/A Revision Date: N/A Surgery - Spine Surgical Procedures on the Nervous System Feed
Vertebral corpectomy (vertebral body resection), partial or complete, combined thoracolumbar approach with decompression of spinal cord, cauda equina, or nerve roots, lower thoracic or lumbar; each additional segment.
Modifier -62 may be applicable if multiple surgeons performed distinct parts of the procedure.Other modifiers may apply depending on circumstances.
Medical necessity is established by the presence of significant neurologic compromise (such as radiculopathy, myelopathy, or cauda equina syndrome) caused by spinal stenosis, fracture, or tumor.The extent of the resection and decompression should be medically justifiable based on the clinical findings and imaging studies.
The surgical team is responsible for the complete procedure, including incision, bone removal, decompression of the spinal cord, nerve roots, or cauda equina, and any additional procedures such as spinal fusion or instrumentation.
In simple words: This code describes a surgery to remove part or all of a vertebra in the lower back. The surgeon uses a combined approach from the middle and lower back to remove the bone and relieve pressure on the spinal cord and nerves.This code is used for each extra vertebra removed beyond the first one.
This CPT code represents a vertebral corpectomy, which involves the partial or complete resection of a lower thoracic or lumbar vertebra using a combined thoracolumbar approach.The procedure includes decompression of the spinal cord, cauda equina, or nerve roots.This code is specifically for each additional segment beyond the initial corpectomy and decompression. It should be reported in addition to the code for the primary procedure (e.g., 63087). The thoracolumbar approach involves an incision made across both the thoracic and lumbar regions of the back to access the affected vertebra.
Example 1: A patient presents with severe spinal stenosis in the lower lumbar region, causing significant radiculopathy.A combined thoracolumbar approach is chosen, and the surgeon performs a corpectomy on L4, followed by decompression of the spinal cord and nerve roots. Due to the extent of the stenosis, an additional corpectomy and decompression of L5 is also performed.Code 63088 would be reported for the L5 corpectomy and decompression, in addition to the code for the primary L4 procedure., A patient with a traumatic vertebral fracture at L3 requiring spinal stabilization undergoes corpectomy of L3, decompression of the spinal cord, and instrumentation.Due to instability, an additional segment (L2) is also resected to improve stability. Code 63088 would be used for the corpectomy and decompression at L2., A patient with a large tumor impinging upon the spinal cord at L1 and L2 presents for surgical resection.A combined thoracolumbar approach is used, and corpectomies are performed at L1 and L2 with decompression.Code 63088 would be reported for the additional segment at L2.
Detailed operative report specifying the approach (combined thoracolumbar), number of vertebral segments resected (including the primary and additional segments), decompression performed, and any additional procedures. Imaging studies (pre-operative and post-operative) demonstrating the extent of the resection and decompression.Pathology report if any tissue was sent for analysis.
** This code is an add-on code and should always be reported with a primary procedure code such as 63087. The number of units reported should accurately reflect the number of additional segments operated on.Appropriate documentation is essential for accurate coding and reimbursement.
- Payment Status: Active
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center