How To Use CPT Code 63191

CPT 63191 describes a surgical procedure that involves the removal of the lamina, which is the arch of the vertebral bone, and a section of the spinal accessory nerve. This article will cover the official description, procedure details, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 63191?

CPT 63191 is a surgical code that represents the removal of the lamina and a section of the spinal accessory nerve. This procedure is typically performed to treat spinal disorders that can cause pain, such as a herniated vertebral disc or lesion. It is important to note that for a bilateral procedure, modifier 50 should be added to the code. Additionally, if the resection of the sternocleidomastoid muscle is performed, a different code, 21720, should be used.

2. Official Description

The official description of CPT code 63191 is: ‘Laminectomy with section of spinal accessory nerve.’

3. Procedure

1. The provider begins by appropriately prepping and draping the patient.
2. An incision is made in the skin and fascia over the vertebrae.
3. The lamina, which is the arch of the vertebral bone, is excised.
4. The provider then incises the spinal accessory nerve.
5. If there is a lesion causing the pain, it is removed.
6. The incision is closed in layers.

4. Qualifying circumstances

CPT 63191 is typically performed on patients with spinal disorders that cause pain, such as a herniated vertebral disc or lesion. The procedure involves the removal of the lamina and a section of the spinal accessory nerve. It is important to note that for a bilateral procedure, modifier 50 should be added to the code. Additionally, if the resection of the sternocleidomastoid muscle is performed, a different code, 21720, should be used.

5. When to use CPT code 63191

CPT code 63191 should be used when a laminectomy with section of the spinal accessory nerve is performed. It is important to ensure that the procedure meets the specific criteria outlined in the official description. If the procedure does not involve the removal of the lamina or section of the spinal accessory nerve, a different code should be used.

6. Documentation requirements

To support a claim for CPT code 63191, the provider must document the following information:

• Patient’s diagnosis and the need for the procedure
• Details of the procedure performed, including the removal of the lamina and section of the spinal accessory nerve
• Date of the procedure
• Any additional procedures performed, such as the resection of the sternocleidomastoid muscle
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT code 63191, it is important to ensure that the procedure meets the specific criteria outlined in the official description. Modifier 50 should be added to the code for a bilateral procedure. If the resection of the sternocleidomastoid muscle is performed, a different code, 21720, should be used. It is also important to follow any additional billing guidelines provided by the payer.

8. Historical information

CPT code 63191 was added to the Current Procedural Terminology system on January 1, 1990. The code has undergone changes over the years, including being added to the Inpatient Only (IPO) list for Medicare in 2017.

9. Examples

1. A patient undergoes a laminectomy with section of the spinal accessory nerve to treat a herniated vertebral disc causing severe pain.
2. A provider performs a laminectomy with section of the spinal accessory nerve to remove a lesion that is compressing a nerve and causing debilitating pain.
3. A patient with a spinal disorder undergoes a laminectomy with section of the spinal accessory nerve to alleviate chronic pain and improve their quality of life.
4. A provider performs a laminectomy with section of the spinal accessory nerve on a patient with a lesion that is causing neurological symptoms and severe discomfort.
5. A laminectomy with section of the spinal accessory nerve is performed on a patient with a spinal disorder to relieve pressure on the nerves and reduce pain.
6. A provider performs a laminectomy with section of the spinal accessory nerve to treat a patient with a herniated vertebral disc that is causing radiating pain and limited mobility.
7. A patient undergoes a laminectomy with section of the spinal accessory nerve to remove a lesion that is causing numbness and tingling in their extremities.
8. A provider performs a laminectomy with section of the spinal accessory nerve on a patient with a spinal disorder to improve their overall function and alleviate pain.
9. A laminectomy with section of the spinal accessory nerve is performed on a patient with a lesion that is causing weakness and loss of sensation in their limbs.
10. A provider performs a laminectomy with section of the spinal accessory nerve to treat a patient with a spinal disorder that is causing chronic, debilitating pain.