How To Use CPT Code 63103

CPT 63103 describes a specific procedure known as vertebral corpectomy, which involves the removal of part or all of a thoracic or 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 63103?

CPT 63103 is a code used to describe a surgical procedure called vertebral corpectomy. This procedure involves the removal of part or all of a thoracic or lumbar vertebral bone and intervertebral disc material. It is typically performed to relieve pressure on the spinal cord and spinal nerves caused by fractures, tumors, or deformities.

2. Official Description

The official description of CPT code 63103 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); thoracic or lumbar, each additional segment (List separately in addition to code for primary procedure).’ This code should be used in conjunction with codes 63101 and 63102.

3. Procedure

1. During a vertebral corpectomy procedure, the provider removes part or all of a thoracic or lumbar vertebral bone and intervertebral disc material.
2. The procedure is performed using a lateral extracavitary approach, which involves making an incision along the middle of the back and then turning sharply toward one side to follow the general direction of the ribs.
3. The provider accesses the additional vertebra through the initial incision or makes a separate incision over another thoracic or lumbar segment.
4. The provider uses surgical tools such as a drill, curette, and rongeurs to remove the transverse processes, facet, pedicle, and central part of the vertebral body.
5. Any bone fragments or tumors along the spinal cord or nerve roots are removed using the curette and rongeurs.
6. The affected intervertebral discs are also removed using these tools.
7. If necessary, the provider may perform fusion, reconstruction, or grafting of the intervertebral body to stabilize the spine.
8. The procedure is completed by placing a drain in the space, closing the opening in layers, and applying sterile dressings.

4. Qualifying circumstances

CPT 63103 is typically performed on patients who require decompression of the spinal cord and/or nerve root(s) due to conditions such as tumors or retropulsed bone fragments. The procedure is performed using a lateral extracavitary approach and may involve the removal of part or all of a thoracic or lumbar vertebral bone and intervertebral disc material.

5. When to use CPT code 63103

CPT code 63103 should be used when a provider performs a vertebral corpectomy procedure using a lateral extracavitary approach to remove part or all of a thoracic or lumbar vertebral bone and intervertebral disc material. This code should be used in addition to the primary procedure codes 63101 and 63102.

6. Documentation requirements

To support a claim for CPT 63103, the provider must document the following information:

• Patient’s diagnosis necessitating the vertebral corpectomy procedure
• Details of the lateral extracavitary approach used
• Specific vertebral bone and intervertebral disc material removed
• Any bone fragments or tumors encountered and removed
• Details of any fusion, reconstruction, or grafting performed
• Date and duration of the procedure
• Any complications or additional procedures performed
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 63103, ensure that the procedure meets the criteria outlined in the official description. It is important to use this code in conjunction with codes 63101 and 63102. Pay attention to any specific billing guidelines provided by insurance carriers or payers.

8. Historical information

CPT code 63103 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 at the thoracic level to remove a tumor and decompress the spinal cord.
2. A provider performs a vertebral corpectomy procedure at the lumbar level to address retropulsed bone fragments and relieve pressure on the nerve roots.
3. During a vertebral corpectomy procedure, a surgeon removes part of a thoracic vertebral bone and intervertebral disc material to treat a deformity and stabilize the spine.
4. A patient with a fracture undergoes a vertebral corpectomy procedure at the lumbar level to remove the affected vertebral bone and intervertebral disc material.