How To Use CPT Code 63056

CPT 63056 describes a specific procedure used to decompress the spinal cord, equina, and/or nerve root(s) in the lumbar region of the 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 63056?

CPT 63056 is a code that represents a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) in the lumbar region of the spine. This procedure is performed to relieve pressure on these structures and is typically used for conditions such as herniated intervertebral discs. The approach involves accessing the spine through the side of the pedicle of a lumbar vertebra.

2. Official Description

The official description of CPT code 63056 is: ‘Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; lumbar (including transfacet, or lateral extraforaminal approach) (eg, far lateral herniated intervertebral disc)’

3. Procedure

1. The provider begins by locating the correct spinal level using fluoroscopy.
2. A midline incision is made over the herniated disc, and the subcutaneous tissues are dissected to the side of the midline.
3. The muscles are elevated and retracted to expose the disc space.
4. Using an operating microscope, the provider removes a piece from the side of the bone that joins the facet joints, along with a portion of the lamina and facet joint.
5. This allows visualization of the disc space, and the provider removes a portion of the lateral part of the protruded disc to decompress the nerve.
6. The provider identifies and removes any calcified or firm disc fragments causing spinal cord compression.
7. An anesthetic may be applied to the nerve root for pain control.
8. The retractors are removed, the layers are reapproximated, and the wound is sutured and dressed.

4. Qualifying circumstances

CPT 63056 is used for patients who require decompression of the spinal cord, equina, or nerve root(s) in the lumbar region of the spine. This procedure is typically performed for conditions such as herniated intervertebral discs. The specific approach used may vary depending on the location and nature of the disc herniation.

5. When to use CPT code 63056

CPT code 63056 should be used when a transpedicular approach is used to decompress the spinal cord, equina, and/or nerve root(s) in the lumbar region of the spine. This code is appropriate for a single segment procedure. It is important to note that CPT code 63056 should not be reported if the procedure involves a different approach, such as a transfacet or lateral extraforaminal approach.

6. Documentation requirements

To support a claim for CPT code 63056, the provider must document the following information:

• Patient’s diagnosis and the need for decompression of the spinal cord, equina, or nerve root(s)
• Specific details of the procedure, including the approach used
• Date of the procedure
• Start and end time of the procedure
• Any complications or additional procedures performed
• Signature of the provider

7. Billing guidelines

When billing for CPT code 63056, ensure that the procedure meets the criteria for a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) in the lumbar region of the spine. It is important to follow the specific documentation requirements and guidelines provided by the payer. Additionally, be aware of any bundling or unbundling rules that may apply to this procedure.

8. Historical information

CPT code 63056 was added to the Current Procedural Terminology system on January 1, 1990. There have been historical changes to the code, including a code change on January 1, 2007. The updated description reflects the inclusion of transfacet or lateral extraforaminal approach for far lateral herniated intervertebral discs.

9. Examples

1. A patient with a herniated lumbar disc undergoes a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) using CPT code 63056.
2. A provider performs a decompression procedure on a patient with a far lateral herniated intervertebral disc in the lumbar region using a transfacet approach.
3. A patient with multiple herniated lumbar discs requires decompression of the spinal cord, equina, and/or nerve root(s) using CPT code 63056 for each affected segment.
4. A provider performs a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) in the lumbar region on a patient with spinal stenosis.
5. A patient with a herniated lumbar disc undergoes a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) using CPT code 63056, along with fusion of the affected segment.