Coding spinal decompression procedures is arguably one of the more challenging tasks for coders—and for good reason. A big part of the difficulty lies in the documentation itself. Providers don’t always give the specific details needed in operative reports, and the code definitions can be tricky to interpret.
Take CPT 63030 as an example:
Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar
What often gets missed is the meaning behind the “and/or excision of herniated disc.” Coders sometimes assume a general decompression qualifies—but this code specifically requires the excision of a herniated disc as the indication for the procedure.
The confusion doesn’t end there. Let’s look at CPT 63047, commonly used for decompression due to spinal stenosis:
Laminectomy, facetectomy and foraminotomy… with decompression of spinal cord, cauda equina and/or nerve root(s)… lumbar
Again, “and/or” can be misleading. But decompression of nerve roots or spinal cord is essential to support this code. And here’s where coders often get tripped up—how do you count the levels?
The code is reported per vertebral segment, not per interspace. The associated add-on code, 63048, is used for each additional segment decompressed.
To clarify:
- A vertebral segment = a single vertebral bone with its joint structures.
- A vertebral interspace = the space between two vertebral bodies (where the disc sits).
Even the AANS supports this, stating a single vertebral segment means per motion segment—the area where decompression typically happens during a foraminotomy.
Understanding these definitions is crucial for accurately reporting posterior spinal decompressions. In future posts, we’ll walk through real-world examples to help you determine how many levels are truly supported in the documentation.
Deanna Upston, CPMA, CPC, COSC
Consultant
Deanna is a consultant for The Haugen Consulting Group with over 20 years of health care industry experience. Her introduction was through medical assisting, which she enjoyed for several years. Once she was established at a surgeon’s office, she started coding their surgical cases and discovered that was her favorite part of the day. Deanna has experience working on the professional fee side of coding, audit, education and compliance serving coders and physicians. She has put together multiple education sessions for both provider and coder. She also has experience working as an analyst in which she validated the integrity of editing logic during the implementation of claim scrubbing software.
Good morning – We are having some confusion regarding the coding of spinal stenosis treated with laminectomy at both L5, S1 levels. Would it be appropriate to code 63047, or 63047, 63048? CPT 63048 does state each additional level cervical, thoracic, lumbar. How do we capture the work performed at the S1 level specifically? Thank you
In order to report spinal decompression procedures, the operative report needs to specify what is being decompressed. Decompression codes 63047-63048 are for a laminectomy/facetectomy/foraminotomy performed to relieve stenosis by decompressing the nerve roots. The provider should document which specific nerve roots are being decompressed. It is my experience that L5-S1 decompression occurs between the levels thus decompressing the L5 nerve roots and nothing is actually being decompressed at the S1. This question cannot be answered any further without reviewing the operative documentation.