How To Use CPT Code 63044

CPT 63044 describes the procedure of laminotomy, which involves the removal of a portion of the laminae to decompress the nerve root(s) and excise a herniated intervertebral disc. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 63044?

CPT 63044 is used to describe a specific surgical procedure called laminotomy. This procedure involves the removal of a portion of the laminae, which are the bony structures that form the posterior part of the vertebral arch. The purpose of laminotomy is to decompress the nerve root(s) and excise a herniated intervertebral disc. It is typically performed in the lumbar region of the spine.

2. Official Description

The official description of CPT code 63044 is: ‘Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; each additional lumbar interspace (List separately in addition to code for primary procedure).’ This code should be used in conjunction with code 63042.

3. Procedure

1. The surgeon begins the laminotomy procedure by making an incision in the patient’s back to access the affected area of the spine.
2. Using specialized surgical instruments, the surgeon removes a portion of the laminae, which are the bony structures that form the posterior part of the vertebral arch.
3. The surgeon then decompresses the nerve root(s) by removing any impinging structures, such as a herniated intervertebral disc or bone spurs.
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. Additionally, a foraminotomy may be performed to enlarge the neural foramen, which is the opening through which the nerve root exits the spinal canal.
6. After completing the decompression and any necessary reexploration, the surgeon closes the incision and the procedure is complete.

4. Qualifying circumstances

CPT 63044 is typically performed on patients who have a herniated intervertebral disc that is causing compression of the nerve root(s) in the lumbar region of the spine. The procedure may also involve the removal of bone spurs or other impinging structures. It is important to note that CPT 63044 should not be reported in conjunction with codes 22630, 22632, 22633, or 22634, which are used for laminotomy procedures performed in preparation for fusion. Additionally, modifier 50 should not be used with CPT 63044 for bilateral procedures.

5. When to use CPT code 63044

CPT code 63044 should be used when a laminotomy procedure is performed to decompress nerve root(s) and excise a herniated intervertebral disc in the lumbar region of the spine. It is important to ensure that the procedure is not being performed in preparation for fusion, as this would require a different set of codes.

6. Documentation requirements

To support a claim for CPT 63044, the surgeon must document the following information:

• Patient’s diagnosis and the need for laminotomy
• Specific details of the procedure performed, including the level(s) of the spine involved
• Any additional procedures performed, such as partial facetectomy or foraminotomy
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and any follow-up appointments scheduled
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT 63044, it is important to ensure that the procedure meets the criteria outlined in the official description. The surgeon should use the appropriate primary procedure code in conjunction with CPT 63044 for each additional lumbar interspace. Modifier 50 should not be used for bilateral procedures; instead, the code should be reported twice. It is also important to follow payer preferences and guidelines when reporting this code.

8. Historical information

CPT 63044 was added to the Current Procedural Terminology system on January 1, 2001. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with a herniated lumbar disc undergoes a laminotomy procedure to decompress the nerve root(s) and excise the herniated disc.
2. A surgeon performs a laminotomy on a patient with spinal stenosis to relieve pressure on the nerve root(s).
3. A patient with a history of chronic back pain undergoes a laminotomy procedure to remove bone spurs and decompress the nerve root(s).
4. A laminotomy is performed on a patient with a herniated disc and radiculopathy to alleviate symptoms and improve function.
5. A patient with a recurrent herniated disc undergoes a laminotomy procedure to remove the disc and decompress the nerve root(s).
6. A surgeon performs a laminotomy on a patient with spondylolisthesis to relieve pressure on the nerve root(s) and stabilize the spine.
7. A laminotomy is performed on a patient with a herniated disc and sciatica to alleviate pain and improve mobility.
8. A patient with spinal instability undergoes a laminotomy procedure to remove a herniated disc and stabilize the spine.
9. A surgeon performs a laminotomy on a patient with foraminal stenosis to enlarge the neural foramen and decompress the nerve root(s).
10. A laminotomy is performed on a patient with a herniated disc and spinal cord compression to relieve pressure on the spinal cord and nerve root(s).