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2025 CPT code 63102

Partial or complete vertebral corpectomy (vertebral body resection) using a lateral extracavitary approach, with decompression of the spinal cord and/or nerve roots; lumbar spine, single segment.

Adhere to the current CPT coding guidelines for spine surgery.Accurate documentation of the surgical approach, extent of resection, and any additional procedures (e.g., fusion) is crucial for proper coding.

Modifiers may be applicable depending on the circumstances of the service.Examples include modifiers for multiple procedures (51), reduced services (52), or assistance (80, 81).

Medical necessity is established by documentation of significant neurological compromise, spinal instability, or unremitting pain caused by the underlying spinal pathology (e.g., tumor, fracture, stenosis).The proposed intervention must be documented as the most appropriate and effective means to treat the condition.

A neurosurgeon or orthopedic spine surgeon is typically responsible for performing this procedure.The surgeon's responsibilities include pre-operative planning, surgical execution, and post-operative care. Anesthesiologist provides anesthesia.

IMPORTANT:63103 (for thoracic or lumbar, each additional segment);Related codes may include those for spinal fusion and instrumentation, depending on the extent of the procedure.

In simple words: This surgery involves removing part or all of a bone in the lower back (lumbar spine) to relieve pressure on the spinal cord or nerves.The surgeon uses a special approach to minimize muscle damage. This may involve adding bone grafts to stabilize the spine.

This code encompasses the surgical removal of a portion or the entirety of a single lumbar vertebral body.The procedure employs a lateral extracavitary approach (LECA), involving a surgical incision that allows access to the vertebra while minimizing disruption of surrounding muscles and tissues.The procedure aims to decompress the spinal cord and/or nerve roots, relieving pressure caused by conditions such as tumors, bone fragments (retropulsed fragments), or other spinal pathologies.The extent of vertebral body resection (partial or complete) is determined by the clinical indication.The procedure may include bone graft or fusion to provide spinal stabilization post-resection.

Example 1: A 55-year-old male presents with severe back pain and neurological deficits due to a large lumbar tumor compressing the spinal cord. A 63102 is performed to remove the tumor and decompress the spinal cord, followed by spinal fusion., A 60-year-old female suffers a burst fracture of L1 in a motor vehicle accident.A 63102 is performed to remove the bone fragments, decompress the spinal cord, and stabilize the spine with instrumentation., A 70-year-old male experiences severe spinal stenosis in the lumbar spine. A 63102 is performed to remove a portion of the vertebral body at L4 to decompress the nerves, followed by a posterior fusion.

Pre-operative imaging (MRI, CT), operative report detailing the approach, extent of resection, decompression achieved, and any instrumentation or fusion performed; post-operative imaging to confirm decompression and stability; pathology report if applicable.

** The lateral extracavitary approach is a key aspect of this procedure, differentiating it from other corpectomy techniques.The code applies to a single lumbar segment; additional segments require the use of 63103.Accurate documentation is critical to ensure proper reimbursement.Consult payer guidelines for specific requirements.

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