2025 CPT code 63057
(Active) Effective Date: N/A Surgery - Surgical Procedures on the Nervous System Surgery Feed
Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (e.g., herniated intervertebral disc), each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure).
Modifiers may be applicable, such as 59 (Distinct Procedural Service) if the additional decompression is performed at a separate anatomical site. Refer to current modifier guidelines.
Medical necessity for the additional decompression should be clearly documented. The documentation must support the presence of pathology requiring surgical intervention at each additional level, such as herniated disc, spinal stenosis, or nerve root compression causing significant symptoms. The patient's symptoms and failed conservative treatment should be clearly documented.
The surgeon performs the decompression through the existing surgical incision or creates new incisions as needed.They identify the affected disc and carefully remove any fragments causing nerve compression, ensuring adequate decompression is achieved.Anesthetic is applied to the nerve root for pain relief.
In simple words: This procedure is an add-on to a primary spinal decompression surgery.It involves relieving pressure on the spinal cord and nerves at additional segments in the thoracic or lumbar spine through a small incision in the back.This is often done when there are multiple herniated discs or other compressions.
This add-on code describes the surgical decompression of the spinal cord, equina, and/or nerve roots through a transpedicular approach, performed on each additional thoracic or lumbar segment during the same operative session.This approach involves accessing the affected disc through the side of the pedicle of the vertebra.It is typically used for herniated intervertebral discs but can also address other conditions requiring decompression. The procedure involves exposing the protruded disc, removing disc fragments causing compression, and applying anesthetic to the nerve root for pain control.
Example 1: A patient presents with multi-level lumbar disc herniations at L3-L4, L4-L5, and L5-S1 requiring surgical decompression. The primary procedure is performed at L4-L5, and 63057 is used to report the additional decompressions at L3-L4 and L5-S1., Following a thoracic disc herniation at T11-T12, a patient undergoes a transpedicular decompression at this level (primary procedure). During the procedure, the surgeon finds a smaller herniation at T10-T11 requiring decompression.63057 would be reported for the T10-T11 decompression., A patient with spinal stenosis at L4-L5 and L5-S1 undergoes a decompression at L4-L5 as the primary procedure. 63057 would be reported for the additional decompression performed at L5-S1 during the same session.
Documentation should support the medical necessity for the additional segment decompressions and describe the operative findings, including the location and severity of the compression.It should also specify the approach used (transpedicular) and the segments treated.
** Always refer to current CPT coding guidelines and NCCI edits before reporting this code. This information is current as of December 1st, 2024 and is subject to change.
- Specialties:Neurosurgery, Orthopedic Surgery
- Place of Service:Inpatient Hospital, Ambulatory Surgical Center