2025 CPT code 63005
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Nervous System - Spinal Surgery Surgery Feed
Laminectomy with exploration and/or decompression of the spinal cord and/or cauda equina, without facetectomy, foraminotomy, or discectomy, for one or two lumbar vertebral segments (excluding spondylolisthesis).
Modifiers 51 (multiple procedures), 52 (reduced services), 59 (distinct procedural service), and others may apply depending on the circumstances of the procedure.
Medical necessity is established by demonstrating significant clinical symptoms (pain, weakness, numbness, bowel/bladder dysfunction) directly correlating with imaging findings of spinal cord or nerve root compression. Conservative treatment options (physical therapy, medication) must be documented as having failed to provide adequate symptom relief.The procedure is medically necessary to improve neurological function and quality of life.
The neurosurgeon or orthopedic surgeon is responsible for performing the laminectomy, ensuring adequate decompression of the spinal cord and/or cauda equina, and managing any complications. Post-operative care involves pain management, mobility assessment and rehabilitation guidance.
In simple words: This surgery involves removing a portion of bone (the lamina) from the back of one or two lower spine bones (vertebrae) to relieve pressure on the spinal cord or nerves.It doesn't include removal of other parts of the bone. The doctor will directly see the area during the operation.
This code encompasses a laminectomy procedure involving the removal of the spinous process and one or both laminae of one or two lumbar vertebrae. The procedure aims to decompress the spinal cord and/or cauda equina.It specifically excludes facetectomy, foraminotomy, or discectomy. The surgical approach is open, with direct visualization of the spine, and focuses on decompression of nerve roots emanating through the foramen.The number of vertebral segments involved determines the appropriate code selection;this code is used when one or two segments are involved and spondylolisthesis is not present.
Example 1: A 60-year-old female patient presents with severe lower back pain radiating down the leg, caused by spinal stenosis (narrowing of the spinal canal). MRI reveals compression of the nerve roots at L4-L5. A laminectomy at L4-L5 is performed to decompress the nerve roots., A 55-year-old male patient with a history of trauma to the lumbar spine experiences chronic lower back pain and weakness in the legs due to spinal cord compression. An MRI shows compression at L3 and L4, with no spondylolisthesis.A laminectomy is performed at L3 and L4 to decompress the spinal cord., A 72-year-old patient with degenerative disc disease presents with significant lower back pain and leg weakness. Imaging confirms spinal stenosis at L5-S1. A laminectomy at L5-S1 is done to decompress the nerve roots and alleviate symptoms, with no other associated procedures performed.
* Preoperative diagnosis supported by imaging studies (MRI, CT scan) showing the level of compression and extent of stenosis.* Operative report detailing the surgical approach, extent of laminectomy (number of vertebrae), and decompression achieved.* Postoperative neurological examination documenting improvement in symptoms.* Pathology reports if any tissue samples were taken.* Any relevant imaging studies performed post-operatively.
** This code should not be used for spondylolisthesis; code 63012 is designated for that condition. Ensure that the procedure performed aligns accurately with the description of this CPT code. Refer to the most current CPT codebook for any recent updates or changes.
- Revenue Code: P1F (Major Procedure - Explor/Decompr/ExcisDisc)
- Payment Status: Active
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center