How To Use CPT Code 63075

CPT 63075 describes a specific surgical procedure used to treat cervical pain caused by a herniated 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 63075?

CPT 63075 is a code used to report a surgical procedure called discectomy. This procedure involves the removal of a herniated disc in the cervical spine to relieve pressure on the nerve roots or spinal cord. It may also include decompression of the spinal cord and/or nerve root(s) and osteophytectomy, which is the removal of bone spurs. This code specifically applies to a discectomy performed through an anterior or anterolateral approach on a single interspace of the cervical spine.

2. Official Description

The official description of CPT code 63075 is: ‘Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, single interspace.’ It is important to note that this code should not be reported in conjunction with code 22554, even if performed by separate individuals. If an anterior cervical discectomy and interbody fusion are performed at the same level during the same session, code 22551 should be used instead.

3. Procedure

1. The surgeon makes a transverse incision in the skin over the herniated disc.
2. The carotid artery and sternocleidomastoid muscle are retracted to access the disc.
3. The surgeon removes the herniated disc material using forceps to decompress the spinal cord and/or nerve roots.
4. Graft bone harvested from the patient’s ilium or another body area is placed into the empty disc space.
5. The muscles and blood vessels are released into place.
6. The incision is closed with layered sutures.

4. Qualifying circumstances

CPT 63075 is used for patients with cervical pain caused by a herniated disc. The herniation occurs when an intervertebral disc moves out of its place and puts pressure on the nerve roots or spinal cord. This condition may result from an accident or pathological causes. The procedure is performed to decompress the spinal cord and/or nerve roots and may involve the removal of bone spurs. It is important to note that CPT 63075 should not be reported with code 22554.

5. When to use CPT code 63075

CPT code 63075 should be used when reporting a discectomy procedure performed through an anterior or anterolateral approach on a single interspace of the cervical spine. It is important to ensure that the procedure meets the specific criteria outlined in the code description. If an anterior cervical discectomy and interbody fusion are performed at the same level during the same session, code 22551 should be used instead of CPT 63075.

6. Documentation requirements

To support a claim for CPT 63075, the following documentation is required:

• Patient’s diagnosis and indication for the discectomy procedure
• Details of the specific interspace and approach used
• Description of the procedure performed, including decompression of the spinal cord and/or nerve root(s) and osteophytectomy if applicable
• Documentation of any graft material used
• Operative report with a step-by-step description of the procedure
• Any additional relevant information or complications encountered during the procedure

7. Billing guidelines

When billing for CPT 63075, it is important to ensure that the procedure meets the specific criteria outlined in the code description. CPT 63075 should not be reported with code 22554. It is also important to follow any additional guidelines provided by the payer or insurance company. Proper documentation is crucial to support the claim for reimbursement.

8. Historical information

CPT 63075 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. It remains an important code for reporting discectomy procedures in the cervical spine.

9. Examples

1. A patient with cervical pain caused by a herniated disc undergoes a discectomy procedure at the C5-C6 level using an anterior approach.
2. A surgeon performs a discectomy procedure through an anterolateral approach to decompress the spinal cord and nerve roots in a patient with cervical pain.
3. A discectomy procedure is performed on a patient with a herniated disc at the C4-C5 level, including decompression of the spinal cord and osteophytectomy.
4. A surgeon removes a herniated disc at the C6-C7 level using an anterior approach, relieving pressure on the nerve roots and spinal cord.
5. A patient with cervical pain caused by a herniated disc undergoes a discectomy procedure at the C3-C4 level, including decompression of the nerve roots and osteophytectomy.
6. A surgeon performs a discectomy procedure through an anterolateral approach to decompress the spinal cord and nerve roots in a patient with cervical pain at the C7-T1 level.
7. A discectomy procedure is performed on a patient with a herniated disc at the C2-C3 level, including decompression of the spinal cord and osteophytectomy.