2025 CPT code 63053
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Nervous System Surgery Feed
Each additional vertebral segment decompression (laminectomy, facetectomy, or foraminotomy) during posterior interbody arthrodesis, lumbar.
Modifiers may be applicable depending on the specific circumstances of the procedure. For instance, modifier 59 may be used to indicate a distinct procedural service.Modifier 78 describes return to the OR for a related procedure. Consult modifier guidelines and payer policies.
Medical necessity for the additional decompression should be supported by documentation of the patient's condition, such as spinal stenosis, nerve root compression, or cauda equina syndrome.The documentation should justify the need for decompression beyond that typically included in the interbody arthrodesis procedure.
The surgeon performs the additional decompression procedure during the same session as the lumbar posterior interbody arthrodesis. This includes procedures like laminectomy, facetectomy, or foraminotomy to decompress the spinal cord, cauda equina, and/or nerve roots.
In simple words: During a lumbar posterior interbody arthrodesis (spinal fusion), if a surgeon performs a decompression procedure (laminectomy, facetectomy, or foraminotomy) on more than one vertebral segment, this code is used for each additional segment after the first.
Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; each additional vertebral segment (List separately in addition to code for primary procedure)
Example 1: A patient undergoes a posterior lumbar interbody fusion (PLIF) at L4-L5 and L5-S1. During the procedure, the surgeon performs a laminectomy at both levels to address stenosis. 63052 would be reported for the decompression at L4-L5, and 63053 would be reported for the additional decompression at L5-S1, along with the appropriate codes for the interbody fusions., A patient has a TLIF at L3-L4 with foraminotomies performed at L3-L4 and L4-L5 during the same session. The primary procedure code for TLIF would be reported, along with 63052 for the foraminotomy at L3-L4, and 63053 for the additional foraminotomy at L4-L5., During a PLIF at L5-S1, the surgeon performs a facetectomy and laminectomy at the same level to relieve nerve compression. In addition, a facetectomy is performed at the L4-L5 level. Code 63052 is reported for the facetectomy and laminectomy at L5-S1, and 63053 is reported for the additional facetectomy at L4-L5, along with the appropriate PLIF code(s).
Documentation should clearly indicate the specific type of decompression performed (laminectomy, facetectomy, foraminotomy), the vertebral segment level where each decompression was performed, and that it was performed during the same operative session as the posterior interbody arthrodesis. The medical necessity for each decompression procedure should also be documented.
** It is crucial to differentiate between decompression procedures performed as part of a posterior interbody arthrodesis and stand-alone decompressions for spinal stenosis, as the coding differs.For stand-alone procedures codes 63047 and 63048 are used instead of 63052 and 63053.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Ambulatory Surgical Center, Inpatient Hospital, Outpatient Hospital