2025 CPT code 63040
(Active) Effective Date: N/A Revision Date: N/A Surgery - Posterior Extradural Laminotomy or Laminectomy Surgical Procedures on the Spine and Spinal Cord Feed
This code represents a re-exploration laminotomy of a single cervical interspace, involving nerve root decompression, partial facetectomy, foraminotomy, and/or herniated disc excision.
Modifiers 50 (bilateral procedure) may be applicable.Add-on codes (63043) require specific documentation of additional levels. Consult payer guidelines on modifier use.
Medical necessity for 63040 is established by the presence of documented persistent or worsening neurological symptoms despite prior surgical intervention. Imaging studies must support the presence of residual pathology requiring re-exploration for decompression.
The neurosurgeon or orthopedic spine surgeon is responsible for performing this procedure, requiring specialized training and experience in spinal surgery.
- Surgical Procedures on the Spine and Spinal Cord
- Surgical Procedures on the Nervous System > Spinal Surgery
In simple words: This surgery is a second look at a previous operation on the neck.The doctor removes a small part of the bone to relieve pressure on a nerve, possibly taking out a herniated disc or doing other necessary procedures.
CPT code 63040 describes a re-exploration laminotomy (hemilaminectomy) of a single cervical interspace.The procedure includes decompression of the nerve root(s), and may involve a partial facetectomy, foraminotomy, and/or excision of a herniated intervertebral disc.It's crucial to note that this code is specifically for re-exploration procedures.
Example 1: A patient underwent a previous cervical laminectomy but continues to experience significant radiculopathy. A re-exploration (63040) is performed to address persistent nerve root compression due to scar tissue formation or recurrent disc herniation., A patient had a previous cervical discectomy but still has persistent neck pain and arm weakness. During the re-exploration (63040), the surgeon discovers residual disc material and performs a more extensive decompression., A patient presented with worsening symptoms after a previous cervical spine fusion. Re-exploration (63040) is necessary to assess the fusion site and address any complications, such as hardware failure or recurrent disc herniation, which could be causing the symptoms.
* Detailed preoperative history and physical examination focusing on neurological deficits and previous surgical interventions.* Preoperative imaging studies (MRI, CT) demonstrating the need for re-exploration and the location of pathology.* Operative report precisely detailing the surgical approach, findings, procedures performed, and any complications encountered.* Postoperative neurological examination documenting the improvement or stabilization of the patient's neurological condition.* Postoperative imaging studies (if applicable) to assess the surgical outcome.
** This procedure is typically performed under general anesthesia, but regional anesthesia may be an option in select cases.The surgeon's judgment regarding the extent of decompression and the need for additional procedures (e.g., facetectomy, foraminotomy, discectomy) will dictate the specifics of the surgical technique.
- Revenue Code: P1F (Major Procedure - Explor/Decompr/ExcisDisc)
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center, Hospital Outpatient