2025 CPT code 63101
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Nervous System Feed
Partial or complete vertebral corpectomy (vertebral body resection) using a lateral extracavitary approach with decompression of spinal cord and/or nerve root(s), for conditions such as tumor or retropulsed bone fragments, at a single thoracic segment.
Modifiers may be applicable. Modifier 22 may be used for increased procedural services. Modifier 59 may be necessary to distinguish the procedure from other services provided.
Medical necessity is established by documenting the patient's neurological symptoms and diagnostic findings (e.g., imaging studies) that demonstrate spinal cord or nerve root compression requiring surgical decompression.
The surgeon makes an incision and exposes the paraspinal muscles, dissects ribs, and removes transverse processes to access the dura and vertebral body. They remove the affected part of the vertebra, disc material, and any fragments or tumors, and may reconstruct and stabilize the spine with grafts or other materials.
In simple words: This procedure removes part of or a whole vertebra in your mid-back to relieve pressure on your spinal cord and nerves. The surgeon goes in through the side of your chest, removing a rib to access the spine. This lets them remove bone and disc material that’s causing problems, and then stabilize the spine with a bone graft or other materials, if necessary.
This procedure involves the removal of a portion or all of a thoracic vertebral body and intervertebral disc material through a lateral extracavitary approach (LECA). The LECA involves a single incision that curves outwards to the side, allowing access to the spine from the side, minimizing disruption to surrounding tissues. The procedure decompresses the spinal cord and/or nerve roots, often to address issues like tumors or retropulsed bone fragments. The surgery may also involve the stabilization of the spine by fusing or reconstructing the affected vertebral segment with bone grafts or other materials.
Example 1: A patient presents with a thoracic spinal tumor causing cord compression. A corpectomy (63101) is performed via a lateral extracavitary approach to remove the tumor and decompress the spinal cord., Following a traumatic thoracic vertebral fracture, a patient experiences nerve root compression due to retropulsed bone fragments. Code 63101 is used to describe the partial corpectomy performed to remove the fragments and decompress the nerve root., A patient with a thoracic disc herniation causing spinal cord compression undergoes a 63101 procedure. The herniated disc and a portion of the vertebral body are removed, and the spine is stabilized with a bone graft.
Documentation should include details of the surgical approach (LECA), the extent of the corpectomy (partial or complete), the specific thoracic level operated on, the reason for the decompression (e.g., tumor, fracture, disc herniation), any spinal stabilization procedures performed, and intraoperative findings.
** For each additional thoracic or lumbar segment addressed during the same session, use add-on code 63103.
- Payment Status: Active
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center