2025 CPT code 63268
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Nervous System Surgery Feed
Laminectomy for excision or evacuation of extradural intraspinal lesion (other than neoplasm); sacral.
Modifiers may apply depending on the circumstances of the procedure (e.g., 59 for distinct procedural service, 22 for increased procedural services, etc.).Refer to the CPT manual for modifier guidelines.
Medical necessity for a laminectomy is established when conservative treatment options (e.g., medication, physical therapy) have failed to alleviate symptoms, and the patient experiences significant pain, neurological deficits (weakness, numbness, bowel/bladder dysfunction) due to compression of the spinal cord or nerve roots by an extradural lesion.Documentation should clearly justify the procedure based on symptoms, imaging, and the failure of conservative treatments.
The neurosurgeon or spine surgeon is responsible for performing this procedure, including pre-operative assessment, surgical technique, post-operative care, and follow up.
In simple words: The doctor removes a part of the bone in the lower back (sacrum) to reach and remove an abnormal growth outside the spinal cord's protective covering. This involves an incision, removal of bone, and then closing the wound.
This procedure involves a laminectomy to access and remove or evacuate an extradural lesion (excluding neoplasms) in the sacral spine.The patient is prepped and positioned prone.An incision is made over the sacral lesion, and dissection proceeds through the tissues to expose the spinal cord.The lamina of the sacral vertebra is removed to access the lesion. The extradural mass is excised or evacuated, and any excess fluid or blood is drained.The wound is then closed in layers.
Example 1: A patient presents with chronic low back pain and neurogenic claudication due to spinal stenosis caused by bone spurs compressing the nerve roots. A laminectomy is performed to decompress the nerve roots., A patient experiences severe pain and weakness in the lower extremities due to an extradural hematoma following a motor vehicle accident.Urgent laminectomy is performed to evacuate the hematoma, relieve pressure and improve neurologic function., A patient with a history of osteomyelitis has a sacral abscess that is compressing the nerve roots.Laminectomy is performed to drain the abscess and alleviate neurological symptoms.
Detailed history and physical examination; pre-operative imaging (MRI, CT); operative report detailing the extent of laminectomy, lesion description and removal, and intraoperative findings; post-operative neurological examination; pathology report if tissue is sent for analysis; post-operative imaging as clinically indicated.
** This code is for extradural lesions excluding neoplasms.Neoplasms would require different coding.
- Revenue Code: P1G (MAJOR PROCEDURE - OTHER)
- RVU: This information is not available in the provided text.Consult the current CPT codebook or a billing resource for RVU values.
- Global Days: This information is not available in the provided text.Consult the current CPT codebook or a billing resource for global period information.The global period likely varies based on payer and other factors.
- Payment Status: Active
- Modifier TC rule: The provided text doesn't specify if a technical component (TC) modifier applies.Consult the CPT manual and payer-specific guidelines for guidance.
- Fee Schedule: This information is not provided.Consult historical CPT code books or billing databases for historical fee schedules.Reimbursement rates vary by payer and location.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center