How To Use CPT Code 63200

CPT 63200 describes the procedure of laminectomy with the release of a tethered spinal cord in the lumbar region. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 63200?

CPT 63200 is used to describe a surgical procedure known as laminectomy with the release of a tethered spinal cord in the lumbar region. This procedure is performed to correct functional abnormalities in the lower extremities caused by a tethered spinal cord. It involves untethering the spinal cord from abnormal tissue attachments that restrict its movement within the spinal column.

2. Official Description

The official description of CPT code 63200 is: ‘Laminectomy, with release of tethered spinal cord, lumbar.’

3. Procedure

1. The patient is prepared and anesthetized, and positioned face down.
2. An incision is made over the area in the lumbar spine where the spinal cord is tethered.
3. The provider gains access to the spinal cord by dissecting and retracting the soft tissues and muscles surrounding the spine.
4. A portion of the lumbar vertebra, called the lamina, is removed through a procedure known as a laminectomy.
5. Using an operating microscope, the provider opens the dural tube, the fibrous sheath covering the spinal cord.
6. The tissue attachments to the end of the spinal cord are released, and the cord and nerve roots are separated from surrounding adhesions and thick fibrous bands to untether the cord.
7. If no additional abnormalities are identified, such as cysts or tumors, the provider reconstructs and closes the dural tube.
8. The layers of muscle, fascia, and skin are closed, and sterile dressings are applied.

4. Qualifying circumstances

CPT 63200 is performed on patients with a tethered spinal cord, which is a congenital or trauma-induced neurological disorder. The procedure is indicated when there are functional abnormalities in the lower extremities, referred to as neurological deficits, and the goal is to stabilize neurologic progression and restore normal movement of the spinal cord within the spinal canal.

5. When to use CPT code 63200

CPT code 63200 should be used when performing a laminectomy with the release of a tethered spinal cord in the lumbar region. It is appropriate when the provider is addressing functional abnormalities in the lower extremities caused by a tethered spinal cord. This code should not be used for procedures performed in other regions of the spine.

6. Documentation requirements

To support a claim for CPT 63200, the provider must document the following information:

• Patient’s diagnosis of a tethered spinal cord and associated functional abnormalities
• Details of the procedure, including the specific lumbar vertebra involved and the extent of the laminectomy
• Description of the release of the tethered spinal cord and any additional procedures performed
• Any additional abnormalities identified during the procedure
• Details of the closure of the dural tube and the layers of muscle, fascia, and skin
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 63200, ensure that the procedure performed is a laminectomy with the release of a tethered spinal cord in the lumbar region. Follow the appropriate coding guidelines and modifiers as required by the payer. It is important to review the payer’s policies and guidelines to ensure accurate and appropriate billing.

8. Historical information

CPT 63200 was added to the Current Procedural Terminology system on January 1, 1990. The code has not undergone any updates since its addition. However, it is important to stay updated with any changes or revisions to the code in future editions of the CPT manual.

9. Examples

1. A patient with a tethered spinal cord undergoes a laminectomy with the release of the cord in the lumbar region to address neurological deficits in the lower extremities.
2. A provider performs a laminectomy with the release of a tethered spinal cord in the lumbar region to stabilize neurologic progression and restore normal movement of the spinal cord.
3. In a surgical procedure, a tethered spinal cord is released through a laminectomy in the lumbar region to correct functional abnormalities in the lower extremities.
4. A patient with a congenital tethered spinal cord undergoes a laminectomy in the lumbar region to untether the cord and improve neurological function.
5. A provider performs a laminectomy with the release of a tethered spinal cord in the lumbar region to address neurological deficits and stabilize the patient’s condition.
6. In a surgical procedure, a provider releases a tethered spinal cord through a laminectomy in the lumbar region to restore normal movement and function.
7. A patient with a tethered spinal cord undergoes a laminectomy in the lumbar region to alleviate neurological deficits and improve overall mobility.
8. A provider performs a laminectomy with the release of a tethered spinal cord in the lumbar region to untether the cord and prevent further neurologic deterioration.