How To Use CPT Code 63268

CPT 63268 describes the procedure for the excision or evacuation of an intraspinal lesion in the sacral spine using a laminectomy technique. 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 63268?

CPT 63268 can be used to describe the surgical procedure performed to remove or evacuate an intraspinal lesion in the sacral spine. This code specifically refers to the use of a laminectomy technique to access and treat the lesion.

2. Official Description

The official description of CPT code 63268 is: ‘Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; sacral.’

3. Procedure

1. During the procedure, the provider makes an incision in the middle of the patient’s back over the location of the sacral lesion.
2. The provider then dissects through the underlying tissue to gain access to the spinal cord.
3. By retracting the soft tissues and adjacent muscles, the provider is able to remove a portion of the sacral vertebra called the lamina.
4. Once the abnormal growth on the dura is located, the provider proceeds to excise or evacuate the entire lesion.
5. If necessary, any excess fluid or blood is drained from the site.
6. The provider then closes the wound in layers and applies a sterile dressing.

4. Qualifying circumstances

CPT 63268 is used for patients who require the excision or evacuation of an intraspinal lesion in the sacral spine. This procedure is typically performed when the lesion is not a neoplasm and is located extradurally. The provider must ensure that the patient meets the necessary criteria for the procedure and that the lesion is appropriately documented.

5. When to use CPT code 63268

CPT code 63268 should be used when a laminectomy is performed to remove or evacuate an intraspinal lesion in the sacral spine. It is important to accurately document the details of the procedure and ensure that the patient meets the qualifying circumstances for this code.

6. Documentation requirements

To support a claim for CPT 63268, the provider must document the following information:

• Patient’s diagnosis and the need for the laminectomy procedure
• Details of the procedure, including the location of the sacral lesion and the use of a laminectomy technique
• Date of the procedure
• Any additional procedures performed during the same session
• Any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans

7. Billing guidelines

When billing for CPT 63268, ensure that the procedure meets the specific criteria outlined in the code description. It is important to accurately document the details of the procedure and any additional services provided. Review the billing guidelines and any applicable modifiers to ensure proper reimbursement for the procedure.

8. Historical information

CPT 63268 was added to the Current Procedural Terminology system on January 1, 1990. It was initially classified as an Inpatient Only (IPO) procedure but was removed from the IPO list in 2020.

9. Examples

1. A patient undergoes a laminectomy procedure to remove an intraspinal lesion in the sacral spine.
2. A provider performs a laminectomy to evacuate an extradural growth in the sacral region.
3. During a surgical procedure, a surgeon excises an intraspinal lesion in the sacral spine using a laminectomy technique.
4. A patient with a sacral lesion undergoes a laminectomy for the removal of the abnormal growth.
5. A provider performs a laminectomy procedure to evacuate an intraspinal lesion in the sacral region.
6. An intraspinal lesion in the sacral spine is successfully removed through a laminectomy procedure.
7. A surgeon performs a laminectomy to excise an extradural growth in the sacral region.
8. A patient undergoes a laminectomy procedure for the evacuation of an intraspinal lesion in the sacral spine.
9. A provider performs a laminectomy to remove an intraspinal lesion in the sacral region.
10. A surgical procedure is performed to excise an extradural growth in the sacral spine using a laminectomy technique.