How To Use CPT Code 63048

CPT 63048 refers to the laminectomy, facetectomy, and foraminotomy procedure performed on an additional vertebral segment during the same session as the initial segment. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 63048.

1. What is CPT 63048?

CPT 63048 is a medical procedure code used to describe the laminectomy, facetectomy, and foraminotomy performed on an additional vertebral segment during the same session as the initial segment. This code is used when the provider performs the procedure on an additional vertebral segment after completing the procedure on the initial segment for decompression.

2. 63048 CPT code description

The official description of CPT code 63048 is: Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional vertebral segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure).

3. Procedure

The 63048 procedure involves the following steps:

  1. Performing laminectomy, facetectomy, and foraminotomy on the initial vertebral segment for decompression.
  2. Performing the procedure on an additional vertebral segment during the same session.
  3. Excising the facet joint between two vertebral bodies for facetectomy.
  4. Excising bone to widen the intervertebral foramen for foraminotomy.
  5. Decompressing the spinal cord, cauda equina, and/or nerve roots by removing any bony or tissue overgrowth around the foramen.
  6. Removing instruments, repositioning tissues, and closing the incision in layers.

4. Qualifying circumstances

Patients eligible to receive CPT code 63048 services are those who require laminectomy, facetectomy, and foraminotomy on an additional vertebral segment during the same session as the initial segment. This may include patients with spinal or lateral recess stenosis, nerve root compression, or other spinal conditions that require decompression of the spinal cord, cauda equina, and/or nerve roots.

5. When to use CPT code 63048

It is appropriate to bill the 63048 CPT code when the provider performs laminectomy, facetectomy, and foraminotomy on an additional vertebral segment during the same session as the initial segment for decompression. This code should be used in conjunction with the primary procedure codes 63045-63047 for the initial vertebral segment.

6. Documentation requirements

To support a claim for CPT 63048, the following information should be documented:

  • Medical necessity for the additional vertebral segment procedure.
  • Detailed description of the procedure performed, including the steps taken and the specific vertebral segments involved.
  • Preoperative and postoperative diagnoses.
  • Any complications or additional procedures performed during the same session.
  • Operative report and any relevant imaging studies.

7. Billing guidelines

When billing for CPT code 63048, it is important to remember that this is an add-on code and should be reported with an appropriate primary code (63045-63047) for the initial vertebral segment. Payers will not reimburse for 63048 unless it is reported with a primary code. Additionally, do not report 63047 and 63048 in conjunction with 22630, 22632, 22633, or 22634 for laminectomy performed to prepare the interspace for fusion on the same interspace(s) and vertebral segment(s). For decompression performed on the same interspace(s) and vertebral segment(s) as posterior interbody fusion that includes laminectomy, removal of facets, and/or opening/widening of the foramen for decompression of nerves or spinal components, see 63052 and 63053.

8. Historical information

CPT 63048 was added to the Current Procedural Terminology system on January 1, 1990. There have been updates to the code description on January 1, 2008, and January 1, 2022.

9. Similar codes to CPT 63048

Five similar codes to CPT 63048 and how they differentiate are:

  • CPT 63045: This code is for the initial vertebral segment procedure, whereas 63048 is for each additional vertebral segment.
  • CPT 63046: Similar to 63045, but for thoracic or lumbar segments instead of cervical.
  • CPT 63047: Similar to 63046, but for each additional thoracic or lumbar segment.
  • CPT 63050: This code is for a different procedure, called laminoplasty, which involves the reconstruction of the vertebral laminae.
  • CPT 63051: Similar to 63050, but for each additional cervical, thoracic, or lumbar segment.

10. Examples

Here are 10 detailed examples of CPT code 63048 procedures:

  1. A patient with spinal stenosis undergoes laminectomy, facetectomy, and foraminotomy on C4-C5 and C5-C6 during the same session.
  2. A patient with bilateral foraminal stenosis at L4-L5 and L5-S1 undergoes laminectomy, facetectomy, and foraminotomy on both levels.
  3. A patient with degenerative disc disease and nerve root compression at T10-T11 and T11-T12 undergoes laminectomy, facetectomy, and foraminotomy at both levels.
  4. A patient with cervical spondylosis and foraminal stenosis at C3-C4 and C4-C5 undergoes laminectomy, facetectomy, and foraminotomy at both levels.
  5. A patient with lumbar spinal stenosis and foraminal stenosis at L3-L4 and L4-L5 undergoes laminectomy, facetectomy, and foraminotomy at both levels.
  6. A patient with thoracic spinal stenosis and nerve root compression at T6-T7 and T7-T8 undergoes laminectomy, facetectomy, and foraminotomy at both levels.
  7. A patient with degenerative disc disease and foraminal stenosis at L2-L3 and L3-L4 undergoes laminectomy, facetectomy, and foraminotomy at both levels.
  8. A patient with cervical spinal stenosis and nerve root compression at C5-C6 and C6-C7 undergoes laminectomy, facetectomy, and foraminotomy at both levels.
  9. A patient with lumbar spondylosis and foraminal stenosis at L1-L2 and L2-L3 undergoes laminectomy, facetectomy, and foraminotomy at both levels.
  10. A patient with thoracic foraminal stenosis at T4-T5 and T5-T6 undergoes laminectomy, facetectomy, and foraminotomy at both levels.

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