How To Use CPT Code 63102

CPT 63102 describes the procedure known as vertebral corpectomy, which involves the removal of part or all of a lumbar vertebral bone and intervertebral disc material. 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 63102?

CPT 63102 is used to describe a surgical procedure called vertebral corpectomy. This procedure involves the removal of part or all of a lumbar vertebral bone and intervertebral disc material. It is typically performed to relieve pressure on the spinal cord and spinal nerves in cases of fractures, tumors, or deformities.

2. Official Description

The official description of CPT code 63102 is: ‘Vertebral corpectomy (vertebral body resection), partial or complete, lateral extracavitary approach with decompression of spinal cord and/or nerve root(s) (eg, for tumor or retropulsed bone fragments); lumbar, single segment.’

3. Procedure

1. The procedure begins with the patient being appropriately prepped and anesthetized.
2. The provider makes a midline incision near the lumbar tumor or fracture and curves the incision outward to the side, exposing the bundle of paraspinal muscles over the target location.
3. The provider elevates and divides the muscles from the ribs and retracts them toward the midline.
4. Using fluoroscopy, the provider identifies the correct lumbar vertebral segment.
5. The provider dissects the associated ribs from the muscles and underlying membrane that lines the lung and wall of the thoracic cavity.
6. Next, the provider resects the ribs in one piece.
7. Using a surgical drill, the provider removes the transverse processes, facet, and pedicle to expose the side of the dura and vertebral body.
8. The provider expands the operative field further by gently retracting the nerve root and surrounding structures.
9. Using the drill and a curette, the provider removes any bone fragments or tumors along the spinal cord or nerve roots.
10. The provider then removes the affected intervertebral disc using the curette and rongeurs.
11. The area is examined for dural tears and hemostasis is obtained.
12. If necessary, the provider may perform fusion, reconstruction, or grafting of the intervertebral body to stabilize the spine.
13. A drain is placed in the space, and the opening is closed in layers with sterile dressings applied.

4. Qualifying circumstances

CPT 63102 is performed on patients who require vertebral corpectomy due to fractures, tumors, or deformities in the lumbar region. The procedure involves the removal of part or all of a lumbar vertebral bone and intervertebral disc material, with decompression of the spinal cord and/or nerve root(s). It is typically performed using a lateral extracavitary approach.

5. When to use CPT code 63102

CPT code 63102 should be used when performing a vertebral corpectomy procedure in the lumbar region. It is important to ensure that the procedure involves the removal of part or all of a lumbar vertebral bone and intervertebral disc material, with decompression of the spinal cord and/or nerve root(s). The use of a lateral extracavitary approach is also a key factor in determining the appropriate usage of this code.

6. Documentation requirements

To support a claim for CPT code 63102, the following documentation is required:

• Patient’s diagnosis necessitating the vertebral corpectomy procedure
• Details of the procedure performed, including the specific lumbar segment involved
• Date of the procedure
• Start and end time of the procedure
• Any additional procedures performed, such as fusion, reconstruction, or grafting
• Any complications or adverse events encountered during the procedure
• Signature of the performing provider

7. Billing guidelines

When billing for CPT code 63102, it is important to ensure that the procedure meets the criteria outlined in the official description. The procedure should involve a partial or complete vertebral corpectomy, performed using a lateral extracavitary approach, with decompression of the spinal cord and/or nerve root(s). It is also important to follow any additional guidelines provided by the payer or coding guidelines.

8. Historical information

CPT code 63102 was added to the Current Procedural Terminology system on January 1, 2004. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient undergoes a vertebral corpectomy procedure in the lumbar region to remove a tumor and decompress the spinal cord.
2. A fracture in the lumbar region necessitates a vertebral corpectomy procedure to stabilize the spine and relieve pressure on the spinal nerves.
3. A patient with a deformity in the lumbar region undergoes a vertebral corpectomy procedure to correct the alignment of the spine and alleviate symptoms.