2025 CPT code 63016
(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, excluding facetectomy, foraminotomy, or discectomy, for more than two thoracic vertebral segments.
Modifiers may be applicable depending on the circumstances of the surgical procedure.Consult the CPT manual and payer guidelines.
Medical necessity is established by documentation of significant clinical symptoms consistent with spinal cord and/or nerve root compression.The preoperative imaging should clearly demonstrate the compression and show that it is impacting the neurologic function.The procedure should be deemed medically necessary to relieve the compression and improve the patient's clinical condition.
The neurosurgeon or spine surgeon is primarily responsible for performing the laminectomy and associated decompression. This involves careful dissection and removal of bone to relieve compression.Postoperative care, including pain management and neurological assessment, is also the responsibility of the surgical team.
In simple words: This surgery involves removing part of the bone (laminae) from the back of more than two vertebrae in the upper back (thoracic spine) to relieve pressure on the spinal cord and nerves. This helps to reduce pain and improve nerve function.This specific procedure does not include the removal of other bone structures (facets or foramen).
This CPT code, 63016, signifies a laminectomy involving more than two thoracic vertebral segments. The procedure includes exploration and/or decompression of the spinal cord and/or cauda equina.It specifically excludes facetectomy, foraminotomy, and discectomy.The laminectomy is performed to alleviate pressure on the spinal cord and nerves, often due to conditions like spinal stenosis. The surgical approach is open, with direct visualization of the spine. The surgeon removes the spinous processes and laminae to create space for the compressed nerves.
Example 1: A 65-year-old female patient presents with severe thoracic back pain radiating down her legs, associated with numbness and weakness, due to significant multi-level spinal stenosis.A laminectomy of three thoracic segments (T6-T8) is performed to decompress the spinal cord and nerve roots., A 50-year-old male patient with a history of trauma has progressive myelopathy secondary to a severe ossification of the posterior longitudinal ligament (OPLL) across multiple thoracic vertebrae. A laminectomy is performed on four thoracic segments (T4-T7)., A 70-year-old patient experiences progressive gait disturbance and sensory loss in her legs due to severe degenerative spondylolisthesis affecting four thoracic vertebrae (T8-T11).Laminectomy is performed across four thoracic segments to alleviate spinal cord and nerve root compression.
Preoperative imaging (MRI, CT scan) clearly demonstrating the spinal stenosis and the level(s) of compression. Operative report detailing the number of vertebral segments involved, extent of laminectomy, and any intraoperative findings.Postoperative neurological examination documenting improvement in symptoms. Pathology report if tissue samples were taken.Anesthesia record.
** Always refer to the most current CPT manual and payer guidelines for the most accurate and up-to-date coding information.This information is for guidance only and should not be considered exhaustive.
- Revenue Code: P1F (Major Procedure - Explor/Decompr/ExcisDisc)
- RVU: Refer to the CMS Physician Fee Schedule for the most up-to-date RVUs.RVUs vary based on geographic location and other factors.
- Global Days: The global period for this procedure needs to be determined based on payer-specific guidelines.It can vary from 0 to 90 days, depending on the surgical package included in the payment.
- Payment Status: Active
- Modifier TC rule: A Technical Component (TC) modifier is not applicable to this code.
- Fee Schedule: Historical fee schedules are not readily available. Refer to historical CPT codebooks and payer records for this information.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center