How To Use CPT Code 63185

CPT 63185 describes a surgical procedure known as rhizotomy, which involves the cutting of nerve roots in the spinal cord to alleviate symptoms of neuromuscular conditions. This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 63185?

CPT 63185 is used to describe a surgical procedure called rhizotomy, which involves the cutting of nerve roots in the spinal cord to relieve symptoms of neuromuscular conditions. This procedure is typically performed through laminotomy or laminectomy under general anesthesia.

2. Official Description

The official description of CPT code 63185 is: ‘Laminectomy with rhizotomy; 1 or 2 segments.’

3. Procedure

1. The patient is positioned face down, and the procedure is performed under general anesthesia.
2. An incision is made along the lower back to access the spinal cord.
3. The surgeon performs a laminectomy, exposing the sensory nerve roots at the center of the spinal cord.
4. Each individual nerve rootlet is electrically stimulated to identify the correct ones to be cut.
5. Any rootlets that cause spasticity when stimulated are cut.

4. Qualifying circumstances

CPT 63185 is used for patients with neuromuscular conditions that require the cutting of nerve roots in the spinal cord for symptom relief. The procedure must be performed by a qualified healthcare professional and involves one or two segments of the spine.

5. When to use CPT code 63185

CPT code 63185 should be used when a laminectomy with rhizotomy procedure is performed on one or two segments of the spine. It is important to accurately document the number of segments involved in the procedure.

6. Documentation requirements

To support a claim for CPT 63185, the following documentation is required:

• Patient’s diagnosis and the need for rhizotomy
• Number of segments involved in the procedure
• Date of the procedure
• Details of the procedure, including the specific nerve rootlets cut
• Any complications or additional procedures performed
• Signature of the healthcare professional performing the procedure

7. Billing guidelines

When billing for CPT 63185, ensure that the procedure involves one or two segments of the spine. It is important to accurately document the number of segments involved in the procedure. CPT code 63185 should not be reported with other codes unless additional procedures were performed. It is recommended to review the specific billing guidelines provided by the payer to ensure accurate reporting.

8. Historical information

CPT code 63185 was added to the Current Procedural Terminology system on January 1, 1990. The code description was updated on January 1, 2009, to specify the inclusion of one or two segments. In 2017, it was added to the Inpatient Only (IPO) list for Medicare.

9. Examples

1. A patient with severe back pain undergoes a laminectomy with rhizotomy procedure on two segments of the spine to alleviate their symptoms.
2. A person with a neuromuscular condition undergoes a laminectomy with rhizotomy procedure on one segment of the spine to relieve spasticity.
3. A patient with chronic leg weakness undergoes a laminectomy with rhizotomy procedure on two segments of the spine to improve their mobility.
4. An individual with persistent muscle spasms undergoes a laminectomy with rhizotomy procedure on one segment of the spine to reduce their spasticity.
5. A patient with neuropathic pain undergoes a laminectomy with rhizotomy procedure on two segments of the spine to alleviate their discomfort.
6. Someone with limited range of motion undergoes a laminectomy with rhizotomy procedure on one segment of the spine to improve their flexibility.
7. A person with muscle stiffness undergoes a laminectomy with rhizotomy procedure on two segments of the spine to relieve their symptoms.
8. An individual with muscle weakness undergoes a laminectomy with rhizotomy procedure on one segment of the spine to enhance their strength.
9. A patient with muscle tightness undergoes a laminectomy with rhizotomy procedure on two segments of the spine to alleviate their tension.
10. Someone with muscle spasms undergoes a laminectomy with rhizotomy procedure on one segment of the spine to reduce their episodes.