How To Use CPT Code 63076

CPT 63076 describes the procedure for anterior cervical discectomy with decompression of the spinal cord and/or nerve root(s), including osteophytectomy. 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 63076?

CPT 63076 is used to report the surgical procedure performed to repair another herniated cervical disc. This procedure involves the removal of the herniated disc material to decompress the spinal cord or nerve roots. The provider may also use grafts to fill the empty space left by the removed disc.

2. Official Description

The official description of CPT code 63076 is: ‘Discectomy, anterior, with decompression of spinal cord and/or nerve root(s), including osteophytectomy; cervical, each additional interspace (List separately in addition to code for primary procedure).’ It is important to note that CPT 63076 should not be reported in conjunction with code 22554, even if performed by separate individuals. To report anterior cervical discectomy and interbody fusion at the same level during the same session, use code 22552. Additionally, CPT 63076 should be used in conjunction with code 63075.

3. Procedure

1. The provider accesses another herniated cervical disc through the initial incision or makes a new incision over the herniated disc.
2. The herniated disc material is removed using forceps to decompress the spinal cord or nerve roots.
3. Graft bone harvested from the ilium or another area of the patient’s body is placed into the disc space to fill the empty space left by the removed disc.
4. The muscles and blood vessels are released into place, and the opening is closed with layered sutures.

4. Qualifying circumstances

CPT 63076 is performed when there is a need to repair another herniated cervical disc. This procedure is typically indicated when medication fails to alleviate the symptoms caused by the herniated disc, such as cervicalgia or neck pain. The herniated disc puts pressure on the nerve roots or spinal cord, causing pain and discomfort. The provider must ensure that the patient meets the criteria for surgical intervention and that the procedure is medically necessary.

5. When to use CPT code 63076

CPT code 63076 should be used when the provider performs an anterior cervical discectomy with decompression of the spinal cord and/or nerve root(s), including osteophytectomy, for an additional interspace in the cervical spine. It is important to note that this code should not be used in conjunction with code 22554 for the same procedure. Additionally, code 63076 should be used in conjunction with code 63075 for the primary procedure.

6. Documentation requirements

To support a claim for CPT code 63076, the provider must document the following information:

• The need for surgical intervention to repair another herniated cervical disc
• The specific procedure performed, including the removal of herniated disc material and decompression of the spinal cord or nerve roots
• The use of graft bone to fill the empty disc space
• The date of the procedure
• The start and end time of the procedure
• Any additional details or complications encountered during the procedure
• The provider’s signature

7. Billing guidelines

When billing for CPT code 63076, it is important to ensure that the procedure meets the criteria for medical necessity and is appropriately documented. The provider should not report code 63076 in conjunction with code 22554 for the same procedure. Additionally, code 63076 should be used in conjunction with code 63075 for the primary procedure. It is important to follow the specific guidelines provided by the payer to ensure accurate and timely reimbursement.

8. Historical information

CPT code 63076 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 undergoes anterior cervical discectomy with decompression of the spinal cord and/or nerve root(s), including osteophytectomy, for the repair of a herniated cervical disc at the C5-C6 level.
2. Another patient requires anterior cervical discectomy with decompression of the spinal cord and/or nerve root(s), including osteophytectomy, for the repair of a herniated cervical disc at the C6-C7 level.
3. A provider performs anterior cervical discectomy with decompression of the spinal cord and/or nerve root(s), including osteophytectomy, for the repair of a herniated cervical disc at the C4-C5 level.
4. During a surgical procedure, the provider accesses another herniated cervical disc through the initial incision and performs anterior cervical discectomy with decompression of the spinal cord and/or nerve root(s), including osteophytectomy, at the C3-C4 level.
5. A patient undergoes anterior cervical discectomy with decompression of the spinal cord and/or nerve root(s), including osteophytectomy, for the repair of a herniated cervical disc at the C7-T1 level.