How To Use CPT Code 63172

CPT 63172 describes a specific procedure involving the removal of the lamina and the drainage of an intramedullary cyst or syrinx into the subarachnoid space. This article will provide an overview of CPT code 63172, including its official description, the procedure itself, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 63172?

CPT 63172 is a code that represents a surgical procedure performed to drain an intramedullary cyst or syrinx into the subarachnoid space. This procedure involves the removal of the lamina, which is the thin bone that forms the back of a vertebra. By draining the cyst or syrinx into the subarachnoid space, the provider aims to alleviate symptoms and improve the patient’s condition.

2. Official Description

The official description of CPT code 63172 is: ‘Laminectomy with drainage of intramedullary cyst/syrinx; to subarachnoid space.’ This code specifically refers to the surgical removal of the lamina and the drainage of an intramedullary cyst or syrinx into the subarachnoid space.

3. Procedure

1. During the procedure, the patient is appropriately prepped and anesthetized, and positioned face down.
2. The provider makes an incision through the skin and fascia near the location of the spinal cyst or syrinx.
3. The muscles near the spine are retracted to gain access to the affected area.
4. A laminectomy is performed, which involves the removal of the lamina, the posterior arch of a vertebra.
5. A spinal needle is then placed into the cyst or syrinx, allowing for the drainage of fluid into the subarachnoid space.
6. The wound is closed in layers, and appropriate post-operative care is provided to the patient.

4. Qualifying circumstances

CPT code 63172 is used when a patient requires the drainage of an intramedullary cyst or syrinx into the subarachnoid space. This procedure is typically performed on patients who are experiencing symptoms related to the cyst or syrinx, such as pain, weakness, or sensory disturbances. The provider must determine that this surgical intervention is necessary to alleviate the patient’s symptoms and improve their overall condition.

5. When to use CPT code 63172

CPT code 63172 should be used when a laminectomy is performed to remove the lamina and drain an intramedullary cyst or syrinx into the subarachnoid space. This code is appropriate when the procedure is performed as a standalone intervention to address the patient’s condition. It is important to note that CPT code 63172 should not be reported if the drainage is performed into the pleural or peritoneal space, as there are separate codes for those scenarios.

6. Documentation requirements

To support a claim for CPT code 63172, the provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the surgical procedure performed, including the removal of the lamina and the drainage of the cyst or syrinx into the subarachnoid space
• Date of the procedure
• Any complications or unexpected findings during the procedure
• Post-operative care provided to the patient
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 63172, it is important to ensure that the procedure performed aligns with the description of the code. The provider must accurately document the removal of the lamina and the drainage of the intramedullary cyst or syrinx into the subarachnoid space. It is also crucial to follow any specific billing guidelines provided by the payer or coding guidelines. Additionally, it is important to review any applicable modifiers or additional codes that may be required to accurately report the procedure.

8. Historical information

CPT code 63172 was added to the Current Procedural Terminology system on January 1, 1990. Since its addition, there have been no updates or changes to the code.

9. Examples

1. A patient with an intramedullary cyst undergoes a laminectomy with drainage into the subarachnoid space to alleviate symptoms and improve their condition.
2. A provider performs a laminectomy with drainage of an intramedullary syrinx into the subarachnoid space for a patient experiencing neurological deficits.
3. A surgical team performs a laminectomy with drainage of an intramedullary cyst into the subarachnoid space to relieve pain and restore function for a patient with spinal cord compression.
4. A provider performs a laminectomy with drainage of an intramedullary syrinx into the subarachnoid space to address sensory disturbances and prevent further neurological deterioration in a patient.
5. A patient with an intramedullary cyst undergoes a laminectomy with drainage into the subarachnoid space to alleviate pain and improve their quality of life.
6. A provider performs a laminectomy with drainage of an intramedullary syrinx into the subarachnoid space to address motor deficits and prevent further neurological damage in a patient.
7. A surgical team performs a laminectomy with drainage of an intramedullary cyst into the subarachnoid space to relieve pressure on the spinal cord and improve the patient’s mobility.