2025 CPT code 63046
(Active) Effective Date: N/A Revision Date: N/A Surgical Procedures on the Nervous System - Spinal Decompression Surgery Feed
Laminectomy, facetectomy, and foraminotomy for a single thoracic vertebral segment, involving decompression of the spinal cord, cauda equina, and/or nerve roots.
Modifiers may be applicable depending on the circumstances.For example, modifier 51 (multiple procedures) would be used if other procedures were performed during the same surgical session. Modifier 22 (increased procedural services) may be used if the procedure was significantly more extensive than usual. Modifiers 59 (distinct procedural service) or 79 (unrelated procedure) may also be appropriate depending on the situation.
Medical necessity for this procedure is established by the presence of clinically significant spinal stenosis, vertebral fracture, or other spinal pathology causing neurological compromise or disabling pain.The decompression surgery is considered medically necessary when conservative treatments have failed to provide adequate relief.
The neurosurgeon or spine surgeon is primarily responsible for this procedure. This includes pre-operative assessment, surgical planning and execution, post-operative care and follow up. Anesthesiologist is responsible for administering anesthesia.Surgical assistants or other healthcare professionals may assist during the surgery.The entire medical team works together to provide complete patient care.
In simple words: This surgical procedure relieves pressure on the spinal cord and nerves in the upper back (thoracic spine).The surgeon removes parts of the bones surrounding the spinal cord and nerves to create more space, easing pain and improving function.
This CPT code, 63046, represents a surgical procedure involving a laminectomy (removal of the lamina—the bony arch of a vertebra), facetectomy (removal of a portion of the articular facet of a vertebra), and foraminotomy (enlargement of the intervertebral foramen—the opening where spinal nerves exit the spine) performed on a single thoracic vertebral segment. The procedure is designed to decompress the spinal cord, cauda equina (the bundle of nerve roots at the end of the spinal cord), and/or nerve roots, often addressing conditions such as spinal stenosis (narrowing of the spinal canal).
Example 1: A 55-year-old patient presents with thoracic spinal stenosis causing significant pain and neurological symptoms.A laminectomy, facetectomy, and foraminotomy are performed at the T6 vertebral level to decompress the spinal cord and nerves., A 60-year-old patient with a history of trauma to the thoracic spine undergoes surgery for a thoracic fracture with associated spinal cord compression. The surgeon performs a laminectomy, facetectomy, and foraminotomy at T4-T5 levels to stabilize the spine and alleviate the compression., A 70-year-old patient experiencing progressive weakness and pain in the upper back from degenerative changes in the spine undergoes a laminectomy, facetectomy, and foraminotomy at the T7 vertebral segment to relieve compression on the spinal nerves.
** Accurate coding requires careful review of the operative report to ensure that all components of the procedure are correctly captured. If multiple vertebral segments are involved, code 63046 should be reported for the first segment and +63048 should be added for each additional segment.Always consult the most recent CPT manual and payer guidelines for definitive coding advice.
- Revenue Code: P1F (MAJOR PROCEDURE - EXPLOR/DECOMPR/EXCISDISC)
- RVU: The relative value units (RVUs) for this code vary based on geographic location, facility type, and other factors. Consult the CMS website or a relevant fee schedule for the most current information.
- Global Days: The global surgical period for this procedure is typically 10 days post-operative, however it could vary depending on additional services provided and payer policies.Additional codes may be necessary to bill for post-operative visits beyond the global period.
- Payment Status: Active
- Modifier TC rule: The application of a technical component (TC) modifier is not usually necessary for this code, as it describes a complete surgical procedure. However, always consult payer guidelines for definitive guidance.
- Fee Schedule: Historical fee schedules for this code are readily available through various online databases and fee-schedule publications.These should be referenced for audit purposes, but payment amounts are dynamic and dependent on many factors, including payer and location.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center