2025 CPT code 63045
(Active) Effective Date: N/A Surgery - Nervous System Feed
Laminectomy, facetectomy, and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (eg, spinal or lateral recess stenosis)), single vertebral segment; cervical.
Modifiers may be applicable. Refer to current CPT guidelines for proper modifier usage.
Medical necessity must be established by documenting the patient's symptoms, neurological findings, and failed conservative treatments. Imaging studies confirming spinal stenosis, herniated disc, or other conditions causing nerve compression should support the need for surgery.
In simple words: This procedure removes bone and enlarges the nerve passageway in your neck to relieve pressure on the spinal cord and nerves.
This code represents a surgical procedure that involves removing a portion of the lamina (the bony arch of the vertebra), part of the facet joint, and enlarging the foramen (the opening where nerve roots exit the spinal canal) in a single cervical vertebra to relieve pressure on the spinal cord, cauda equina, and/or nerve roots.
Example 1: A patient presents with cervical radiculopathy due to spinal stenosis at C5. The surgeon performs a laminectomy, facetectomy, and foraminotomy at C5 to decompress the nerve root., A patient with a herniated disc at C6-C7 undergoes a laminectomy, facetectomy, and foraminotomy at C6 to remove the disc material and decompress the spinal cord., A patient experiences cervical myelopathy due to spinal stenosis at C3-C4 and C4-C5. A laminectomy, facetectomy, and foraminotomy are performed at C4, followed by additional decompression at C3 using add-on code +63048.
Documentation should include the diagnosis, operative report detailing the specific levels and extent of the procedure (unilateral or bilateral), and any associated procedures performed. Pre- and post-operative imaging may also be necessary.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center