How To Use CPT Code 63055

CPT 63055 describes a specific procedure used to relieve pressure on the spinal cord, equina, or nerve roots in the thoracic spine. 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 63055?

CPT 63055 is a code used to describe a procedure that involves the transpedicular approach for decompression of the spinal cord, equina, and/or nerve root(s) in the thoracic spine. This procedure is performed to relieve pressure on these structures caused by a bulging disc or other conditions.

2. Official Description

The official description of CPT code 63055 is: ‘Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; thoracic.’

3. Procedure

1. The provider begins by using fluoroscopy to locate the correct spinal level in the thoracic spine.
2. A lateral incision is made over the spine at the levels adjacent to the herniated disc.
3. The provider then dissects through the tissue, retracts the soft tissues, and dissects the adjacent muscles.
4. Using an operating microscope for visualization, the provider locates the pedicle adjacent to the herniated disc space.
5. The facet joint and lamina of the pedicle are exposed and removed.
6. The provider then incises the lateral disc space of the protruded disc, identifying the disc fragments from normal disc material.
7. Calcified or firm disc fragments causing spinal cord compression are removed.
8. Once adequate decompression is achieved, the retractors are removed, the layers are reapproximated, and the wound is sutured and dressed.

4. Qualifying circumstances

CPT 63055 is performed when there is a bulging disc in the thoracic spine that is causing pressure on the spinal cord, equina, or nerve roots. This procedure is typically done for lateral disc bulges, where the bulge is towards the left or right side of the spinal canal. It is important to note that this procedure is specific to the thoracic spine and should not be used for other regions of the spine.

5. When to use CPT code 63055

CPT code 63055 should be used when a provider performs a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) in the thoracic spine. It is important to ensure that the procedure is performed on a single segment in the thoracic spine and not on other regions of the spine.

6. Documentation requirements

To support a claim for CPT 63055, the provider must document the following information:

• Patient’s diagnosis and the need for decompression of the spinal cord, equina, and/or nerve root(s)
• Specific segment in the thoracic spine where the procedure was performed
• Date of the procedure
• Details of the procedure, including the approach used and the steps performed
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 63055, it is important to ensure that the procedure was performed on a single segment in the thoracic spine. This code should not be reported with other codes for decompression procedures on different regions of the spine. It is also important to follow any specific guidelines provided by the payer regarding documentation and billing for this procedure.

8. Historical information

CPT 63055 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates or changes to the code since its addition.

9. Examples

1. A patient with a bulging disc in the thoracic spine undergoes a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) at a single segment.
2. A provider performs a decompression procedure on a patient with a lateral disc bulge in the thoracic spine using a transpedicular approach.
3. A patient with pressure on the spinal cord in the thoracic spine undergoes a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) at a single segment.
4. A provider performs a decompression procedure on a patient with nerve root compression in the thoracic spine using a transpedicular approach.
5. A patient with a herniated intervertebral disc in the thoracic spine undergoes a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) at a single segment.
6. A provider performs a decompression procedure on a patient with a bulging disc causing spinal cord compression in the thoracic spine using a transpedicular approach.
7. A patient with nerve root compression in the thoracic spine undergoes a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) at a single segment.
8. A provider performs a decompression procedure on a patient with a herniated intervertebral disc in the thoracic spine using a transpedicular approach.
9. A patient with pressure on the spinal cord in the thoracic spine undergoes a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) at a single segment.
10. A provider performs a decompression procedure on a patient with nerve root compression in the thoracic spine using a transpedicular approach.