How To Use CPT Code 62380

CPT 62380 describes the endoscopic decompression of the spinal cord and nerve roots, including laminotomy, partial facetectomy, foraminotomy, discectomy, and/or excision of herniated intervertebral disc at a single interspace level. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 62380?

CPT 62380 is used to describe the endoscopic decompression of the spinal cord and nerve roots, along with the removal of a herniated intervertebral disc. This procedure is performed at a single interspace level using an endoscopic approach. It involves the removal of the bulging disc and the bony portions of the surrounding vertebrae to relieve pressure on the spinal cord and nerve roots, providing relief for patients with back pain.

2. Official Description

The official description of CPT code 62380 is: ‘Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar.’

3. Procedure

1. The provider begins by prepping and anesthetizing the patient.
2. Contrast is injected into the nucleus of the suspect spinal disc to visualize the disc and any protruding material under imaging guidance.
3. An endoscope is introduced through an endoscope sheath inserted over a guidewire, following needle localization.
4. The provider removes some or all of the disc material, either manually or using an automated device, radiofrequency ablation, or laser energy.
5. In addition to the discectomy, the provider may perform a laminotomy, foraminotomy, and/or facetectomy to ensure complete decompression of the spinal cord and nerve roots.
6. The surgical area is irrigated, instruments are removed, and the incisions are closed.

4. Qualifying circumstances

CPT 62380 is performed on patients with back pain who require decompression of the spinal cord and nerve roots. The procedure is typically done using an endoscopic approach at a single interspace level. It is important to note that this code should not be reported for open procedures or for bilateral procedures without the appropriate modifier.

5. When to use CPT code 62380

CPT code 62380 should be used when the provider performs endoscopic decompression of the spinal cord and nerve roots, along with the removal of a herniated intervertebral disc, at a single interspace level. It is important to ensure that the procedure is performed using an endoscopic approach and at the appropriate level.

6. Documentation requirements

To support a claim for CPT code 62380, the provider must document the following information:

• Patient’s diagnosis and the need for decompression of the spinal cord and nerve roots
• Details of the endoscopic approach and the specific procedures performed, such as laminotomy, partial facetectomy, foraminotomy, discectomy, and/or excision of herniated intervertebral disc
• Location of the procedure (single interspace level)
• Date of the procedure
• Any additional relevant information, such as the use of contrast or the use of specific instruments or techniques
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 62380, it is important to ensure that the procedure is performed using an endoscopic approach and at a single interspace level. Fluoroscopic guidance should not be separately reported as it is included in this code. Additionally, if the procedure is performed bilaterally, the appropriate modifier should be used. It is important to review the specific billing guidelines and requirements of the payer to ensure accurate and appropriate billing.

8. Historical information

CPT code 62380 was added to the Current Procedural Terminology system on January 1, 2017. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with chronic back pain undergoes endoscopic decompression of the spinal cord and nerve roots, along with the removal of a herniated intervertebral disc, at the L4-L5 level.
2. An individual with radiculopathy in the lumbar region undergoes endoscopic decompression of the spinal cord and nerve roots, along with the removal of a herniated intervertebral disc, at the L5-S1 level.
3. A patient with spinal stenosis undergoes endoscopic decompression of the spinal cord and nerve roots, along with the removal of a herniated intervertebral disc, at the L3-L4 level.