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2025 CPT code 63278

Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, sacral.

Adhere to current CPT coding guidelines and the official coding manuals for accurate reporting of this procedure.Proper documentation is essential to ensure accurate coding and reimbursement.

Modifiers may apply depending on the circumstances of the procedure.Consult the CPT manual and payer guidelines for appropriate modifier usage.

Medical necessity for this procedure is established through documentation demonstrating a symptomatic extradural sacral neoplasm causing neurological deficits or significant pain that cannot be managed conservatively.The surgical intervention is expected to improve neurological function and/or alleviate symptoms.

A neurosurgeon or spine surgeon is typically responsible for performing this procedure.The clinical responsibility involves pre-operative planning, intra-operative surgical technique and post-operative patient care including management of complications.

IMPORTANT:Related codes may include those for laminectomy with different approaches or locations (e.g., lumbar, thoracic) and for excision of other intraspinal lesions.Specific codes may vary depending on the type and location of the lesion.

In simple words: The doctor removes part of a bone in the lower back (sacrum) to reach and take out a tumor outside the spinal cord's protective covering. A sample of the tumor is tested, and then the whole tumor is removed.

This procedure involves a laminectomy, the surgical removal of a portion of the vertebral lamina (posterior arch of a vertebra), specifically in the sacral region of the spine.The objective is to access and remove an extradural (outside the dura mater) spinal neoplasm (tumor). A biopsy is taken and sent to pathology for confirmation, followed by complete excision of the lesion.Hemostasis (control of bleeding) is ensured and the surgical site is closed in layers.

Example 1: A 60-year-old patient presents with progressive lower back pain and neurological deficits indicative of a sacral extradural tumor.A laminectomy is performed to excise the tumor, relieving pressure on the nerves and improving neurological function., A 45-year-old patient undergoes a biopsy of a suspected sacral extradural lesion. The biopsy confirms a neoplasm and a subsequent laminectomy with excision is conducted., A 72-year-old patient with a history of metastatic cancer develops a sacral extradural mass causing significant pain and neurological symptoms.A debulking laminectomy is performed to palliate symptoms.

** The specific surgical approach and techniques may vary depending on the surgeon’s preference and the location and size of the tumor.Detailed documentation is crucial for appropriate coding and reimbursement.

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