2025 CPT code 63044
(Active) Effective Date: N/A Revision Date: N/A Surgery - Laminectomy/Lamintomy Surgical Procedures on the Spine and Spinal Cord Feed
This CPT code represents a re-exploration laminotomy of each additional lumbar interspace, including nerve root decompression, partial facetectomy, foraminotomy, and/or herniated disc excision.
Modifiers 50 (bilateral procedure) and others as appropriate per payer guidelines.
Medical necessity for this add-on code is established by pre-operative imaging demonstrating persistent or new nerve compression at an additional interspace(s) not addressed in prior surgery.Symptoms of nerve root compression (radiculopathy) must be clinically documented. The procedure should alleviate the existing nerve compression.
The clinical responsibility rests with the surgeon who performs the laminotomy, decompression, facetectomy, foraminotomy, and/or disc excision.This includes pre-operative assessment, surgical planning, execution of the surgical technique, post-operative care, and management of any complications.Appropriate surgical expertise in spinal surgery is required.
In simple words: This code covers additional surgery on the lower back (lumbar spine) to relieve pressure on nerves. It's only used if a similar operation has already been performed and more work is needed at another level.The surgery involves removing parts of the bone to create more space and may also involve removing a herniated disc.
CPT code 63044 describes a re-exploration laminotomy for each additional lumbar interspace. This procedure involves decompression of the nerve root(s), and may include a partial facetectomy, foraminotomy, and/or excision of a herniated intervertebral disc.It is an add-on code and should be reported in addition to the primary procedure code for a single interspace laminotomy (63042). The procedure is considered a re-exploration, indicating a prior surgical intervention at the same site.
Example 1: A patient presents with persistent radiculopathy (nerve pain) in the lower back and leg despite a previous lumbar laminectomy at L4-L5.An MRI reveals significant nerve root compression at L5-S1, necessitating a re-exploration laminotomy at L5-S1 with decompression. Code 63044 would be reported in addition to the code for the initial L4-L5 laminectomy., A patient undergoes a lumbar discectomy at L4-L5. During the procedure, it's discovered that there is additional herniated disc material at L5-S1 causing further nerve compression.The surgeon decides to perform an add-on laminotomy at L5-S1 with decompression of the nerve root. Code 63044 is used to report the additional procedure., Following a previous spinal fusion surgery, a patient experiences continued pain and neurological deficit due to stenosis (narrowing) at adjacent levels. After imaging studies, the physician elects to perform a re-exploration laminotomy at those levels, with decompression of the affected nerve roots. This will require the use of 63044 in addition to the primary procedure code.
Detailed operative notes describing the surgical approach, level of intervention, extent of decompression, any facetectomy or foraminotomy, disc excision, and findings.Pre-operative imaging (MRI, CT) demonstrating the need for the procedure.Post-operative imaging may be required depending on payer requirements.Complete anesthesia record, pathology report if disc tissue removed.
** Always confirm payer-specific coding and reimbursement policies before submitting claims.Thorough documentation is crucial for appropriate reimbursement.
- Revenue Code: P1F
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center