How To Use CPT Code 63040

CPT 63040 describes the procedure of laminotomy (hemilaminectomy) with decompression of nerve root(s), including partial facetectomy, foraminotomy, and/or excision of herniated intervertebral disc, reexploration, in a single cervical interspace. This article will cover the description, official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 63040?

CPT 63040 is used to describe a specific surgical procedure called laminotomy, which involves the removal of the upper and lower portions of adjacent laminae in a single cervical interspace. This procedure is performed to decompress nerve root(s) and may also include partial facetectomy, foraminotomy, and/or excision of a herniated intervertebral disc. It is important to note that this procedure is a reexploration, meaning it is performed after a previous surgery in the same area.

2. Official Description

The official description of CPT code 63040 is: ‘Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; cervical.’ This code is specifically used for procedures performed in the cervical region.

3. Procedure

1. The surgeon begins the procedure by making an incision in the appropriate location on the patient’s neck.
2. The upper and lower portions of adjacent laminae in a single cervical interspace are removed, creating a small opening known as a laminotomy.
3. The surgeon then decompresses the nerve root(s) by removing any structures or tissues that may be compressing them, such as a herniated intervertebral disc.
4. If necessary, the surgeon may also perform a partial facetectomy, which involves removing a portion of the facet joint to further decompress the nerve root(s).
5. A foraminotomy may be performed to enlarge the neural foramen, the opening through which the nerve root exits the spinal canal.
6. After completing the necessary decompression and other procedures, the surgeon may reexplore the area to ensure that all necessary steps have been taken.
7. The incision is then closed, and the patient is moved to a recovery area.

4. Qualifying circumstances

CPT 63040 is typically performed on patients who have already undergone a previous surgery in the same cervical interspace and require further decompression of nerve root(s). The procedure may be necessary due to persistent symptoms or the development of new symptoms. It is important to note that this procedure is specific to the cervical region and should not be used for procedures performed in other areas of the spine.

5. When to use CPT code 63040

CPT code 63040 should be used when a surgeon performs a laminotomy with decompression of nerve root(s), including partial facetectomy, foraminotomy, and/or excision of herniated intervertebral disc, as a reexploration in a single cervical interspace. It is important to ensure that the procedure is performed in the cervical region and that it meets the specific criteria outlined in the code description.

6. Documentation requirements

To support a claim for CPT code 63040, the surgeon must document the following information:

• Indication for the procedure, including the patient’s symptoms and the need for reexploration
• Details of the procedure performed, including the specific structures addressed (e.g., nerve root(s), herniated intervertebral disc)
• Any additional procedures performed, such as partial facetectomy or foraminotomy
• Location of the procedure (cervical)
• Date of the procedure
• Any complications or unexpected findings
• Signature of the surgeon

7. Billing guidelines

When billing for CPT code 63040, it is important to ensure that the procedure meets the specific criteria outlined in the code description. Modifier 50 should be appended to the code if the procedure is performed bilaterally. It is also important to follow payer preferences regarding the reporting of add-on codes and to report the appropriate add-on code (+63043 for cervical) for each additional level, if applicable.

8. Historical information

CPT code 63040 was added to the Current Procedural Terminology system on January 1, 1990. There have been a few changes to the code description over the years, including updates to the terminology used and the addition of specific modifiers for reporting bilateral procedures.

9. Examples

1. A patient who previously underwent a cervical laminectomy presents with persistent symptoms. The surgeon performs a laminotomy with decompression of nerve root(s), including partial facetectomy, foraminotomy, and excision of a herniated intervertebral disc in a single cervical interspace.