2025 CPT code 63048
(Active) Effective Date: N/A Revision Date: N/A Surgery - Spine Surgical Procedures on the Nervous System Feed
Additional vertebral segment decompression following laminectomy, facetectomy, and foraminotomy.
Modifiers may be applicable depending on the circumstances of the procedure.Consult CPT guidelines for appropriate modifier usage.
Medical necessity is established by the presence of significant symptomatic spinal stenosis causing neurogenic claudication, radiculopathy, or myelopathy. Pre-operative imaging studies must demonstrate spinal canal or nerve root compression at the levels treated. The procedure must be performed by a qualified surgeon.
The neurosurgeon or spine surgeon is responsible for performing the laminectomy, facetectomy, and foraminotomy, including the decompression of the spinal cord, cauda equina, and/or nerve root(s). This includes appropriate patient preparation, anesthesia, surgical technique, and wound closure. Postoperative care is also the responsibility of the surgeon.
In simple words: This code is for extra work done on the spine during the same surgery.If a surgeon already did a procedure to remove pressure on the nerves in one part of the spine, this code is used for each additional part of the spine that needs the same treatment. It's only billed if another main code for the first part of the spine surgery is also billed.
This CPT code, 63048, represents the decompression of each additional vertebral segment performed during the same session as a laminectomy, facetectomy, and foraminotomy on an initial segment.The procedure involves the excision of a vertebral lamina (laminectomy), excision of the facet joint (facetectomy), and excision of bone to widen the intervertebral foramen (foraminotomy) to decompress spinal cord, cauda equina, and/or nerve roots. The services may be unilateral or bilateral. This code is an add-on code and must be reported in addition to the primary procedure code (63045-63047) for the initial vertebral segment.It is not reported with codes 22630, 22632, 22633, 22634 for laminectomy performed to prepare the interspace for fusion on the same interspace(s) and vertebral segment(s). For decompression performed on the same interspace(s) and vertebral segment(s) as posterior interbody fusion that includes laminectomy, removal of facets, and/or opening/widening of the foramen for decompression of nerves or spinal components, use codes 63052 or 63053.
Example 1: A patient presents with multilevel cervical stenosis.The surgeon performs an anterior cervical discectomy and fusion (ACDF) at C5-C6 and C6-C7.During the same operative session, the surgeon also performs laminectomy, facetectomy, and foraminotomy at C5 and C6, for nerve root decompression.Code 63048 would be used to report the additional C6 segment decompression.The primary code would be 63047 for the initial segment (C5). , A patient presents with lumbar spinal stenosis affecting L3, L4, and L5. A laminectomy, facetectomy and foraminotomy are performed at L4 (primary code 63047).Because there is significant foraminal stenosis at L3 and L5,63048 would be used twice (one for L3 and one for L5) as an add-on code to 63047 for additional segment decompression., A patient has a severe spinal stenosis at the L4-L5 level and also shows evidence of nerve root compression at L3.During the surgical decompression at L4-L5, the surgeon identifies and treats compression at L3 with a laminectomy. The surgeon would use 63047 to represent the L4-L5 decompression and 63048 to represent the decompression at L3.
Operative report detailing the procedures performed (laminectomy, facetectomy, foraminotomy) and the vertebral levels involved.Preoperative imaging studies (MRI, CT scan) demonstrating the stenosis and nerve root compression.Postoperative imaging may be helpful to assess the decompression.Patient history and physical examination findings demonstrating the symptoms and their improvement after the procedure. Anesthesia record.
** Accurate coding requires thorough review of the operative report to identify the specific vertebral segments involved in the decompression.The number of reported units of 63048 should match the number of additional segments decompressed.
- Revenue Code: P1F (Major Procedure - Exploration/Decompression/Excision Disc)
- RVU: Information not available.RVUs vary based on geographic location and other factors. Consult a relevant fee schedule.
- Global Days: Information not available in provided text. Global surgical periods vary depending on payer and procedure.Consult payer guidelines.
- Payment Status: Active
- Modifier TC rule: Not applicable.This is not a procedure that would have a technical component.
- Fee Schedule: Information not available. Fee schedules vary by payer and location.Consult payer-specific fee schedules.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center