How To Use CPT Code 63057

CPT 63057 describes the procedure for a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) in the thoracic or lumbar 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 63057?

CPT 63057 is a code used to describe a specific surgical procedure that involves the transpedicular approach for decompression of the spinal cord, equina, and/or nerve root(s) in the thoracic or lumbar spine. This procedure is performed to alleviate pressure on the affected nerves and provide relief from symptoms caused by a herniated intervertebral disc or other spinal conditions.

2. Official Description

The official description of CPT code 63057 is: ‘Transpedicular approach with decompression of spinal cord, equina and/or nerve root(s) (eg, herniated intervertebral disc), single segment; each additional segment, thoracic or lumbar (List separately in addition to code for primary procedure).’ This code should be used in conjunction with codes 63055 and 63056 for primary procedures.

3. Procedure

1. In this procedure, the healthcare provider accesses the affected disc through the side of the pedicle of another thoracic or lumbar vertebra using the transpedicular approach.
2. After making the initial incision or accessing the area over the herniated disc, the provider decompresses the nerve by removing the protruded disc fragments that are causing compression.
3. The provider may use instrumentation during the procedure to aid in decompression.
4. An anesthetic may be applied to the nerve root for pain control.
5. Once adequate decompression is achieved, the provider removes any instrumentation used, reapproximates the layers, sutures the wound, and applies a sterile dressing.

4. Qualifying circumstances

CPT 63057 is performed on patients who have a herniated intervertebral disc or other spinal condition that requires decompression of the spinal cord, equina, and/or nerve root(s) in the thoracic or lumbar spine. The procedure is typically performed by a qualified healthcare provider who specializes in spinal surgery.

5. When to use CPT code 63057

CPT code 63057 should be used when a transpedicular approach is used to decompress the spinal cord, equina, and/or nerve root(s) in the thoracic or lumbar spine. This code is used for each additional segment that requires decompression in addition to the primary procedure. It should not be reported for a herniated disc in conjunction with other codes for decompression on the same interspace(s) and vertebral segment(s).

6. Documentation requirements

To support a claim for CPT code 63057, the healthcare 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 segments of the thoracic or lumbar spine that require decompression
• Details of the transpedicular approach used
• Date and duration of the procedure
• Procedure notes detailing the steps taken during the decompression
• Any instrumentation used during the procedure
• Any complications or unexpected findings
• Signature of the healthcare provider performing the procedure

7. Billing guidelines

When billing for CPT code 63057, ensure that the procedure meets the criteria for this code, including the use of the transpedicular approach and decompression of the spinal cord, equina, and/or nerve root(s) in the thoracic or lumbar spine. It is important to follow the guidelines for reporting this code in conjunction with other codes for primary procedures and to avoid reporting it for the same interspace(s) and vertebral segment(s) as other decompression procedures.

8. Historical information

CPT code 63057 was added to the Current Procedural Terminology system on January 1, 1990. There have been no updates to the code since its addition.

9. Examples

1. A patient with a herniated disc in the lumbar spine undergoes a transpedicular approach with decompression of the spinal cord, equina, and/or nerve root(s) in a single segment.
2. A patient with multiple herniated discs in the thoracic spine requires decompression of each segment using the transpedicular approach.
3. A patient with a herniated disc in the lumbar spine undergoes decompression of the spinal cord, equina, and/or nerve root(s) in multiple segments using the transpedicular approach.
4. A patient with a herniated disc in the thoracic spine undergoes decompression of the spinal cord, equina, and/or nerve root(s) in a single segment using the transpedicular approach.
5. A patient with a herniated disc in the lumbar spine undergoes decompression of the spinal cord, equina, and/or nerve root(s) in a single segment using the transpedicular approach, in addition to a primary procedure for posterior interbody fusion.