Spine Line - November/December 2009

Coding Transpedicular Approach for Lumbar
Posterolateral, Extradural Exploration/
Decompression (63056-63057) versus
Percutaneous Disc Decompression (62287)
versus Annuloplasty (22526-22527)

David O’Brien Jr, MD
Co-Chair, NASS Coding Committee
Orthopaedic Specialists of the
Carolinas, PA
Winston Salem, NC

Christopher Kauffman, MD
Co-Chair, NASS Coding Committee
Tennessee Orthopaedics
Gallatin, TN

The North American Spine Society (NASS) provides answers to its members’ inquiries regarding CPT coding as an educational service to its members. The answers expressed by the NASS Coding Committee are in response to a specific fact situation presented and based on their interpretation of the AMA CPT® code book. The answers given by the committee should not be relied upon as official interpretations of the AMA CPT® code book. The American Medical Association is the only entity, which can give an official and binding interpretation of the AMA CPT® code book, and should be contacted directly if an official comment is needed or desired. For more information contact the AMA’s CPT® Network at www.cptnetwork.com.

Transpedicular Posterolateral
Decompression

Patients with symptomatic far lateral disc herniations, such as foraminal or extraforaminal herniations, may be appropriate candidates for an open discectomy using a posterolateral or transpedicular approach (CPT code 63056). This open surgical procedure may be performed with the assistance of an operating microscope. The surgery requires direct visualization of the disc herniation and of the decompressed nerve root(s). Code 63056 is not an endoscopic or endoscopically–assisted code. The only discectomy codes which include endoscopic assistance are 63020, 63030 and 63035.

Code 63056 was added to CPT in 1980, revised in 2000 and is currently considered an inpatient surgery with hospitalization code. The original code described a transpedicular vertebrectomy, as performed when treating a fracture with neurological compression. As with all corpectomy codes, it includes resection of the body and the discs above and below. This level of work, assigned 38. 43 RVUs, included 170 minutes of intraservice time and seven days of postoperative hospitalization. Assistants or cosurgeons are allowed and the procedure has a 90-day global period. The 2000 editorial change folded in open treatment of far lateral disc herniations when done by the transforaminal or Wiltse approach.

Newer endoscopic techniques have been
developed over the years allowing for less
invasive approaches to these disc hernia-
tions. These new techniques are not used for
transpedicular corpectomy. Most commonly,
the patient goes home the same day and the
procedures are often performed in an ASC
setting. The 63056 code does not accurately
describe this procedure. Our suggestion when
performing these procedures is for an unlisted
code 64999 or 22899.

Percutaneous Disc Decompression Lumbar percutaneous disc decompression (PDD) uses a posterior-lateral approach similar to the endoscopic procedures mentioned above. The percutaneous procedures do not directly visualize the fragment, however. They are indicated, therefore, to treat contained disc herniations/protrusions. The typical patient suffers from radicular pain due to a disc protrusion pressing on a spinal nerve. PDD removes nuclear material from the disc center thereby reducing intradiscal pressure. Typically, the device is inserted under fluoroscopic guidance and the nuclear material is removed with thermal vaporization, ablation, or direct extraction. Theoretically, this pressure reduction indirectly decreases the size of the contained disc herniation. Although a physician may make a small incision and perform some degree of blunt dissection to advance the needle or trochar toward the disc, the surgery is primarily performed percutaneously. Some devices, such as Lase,™ use a fiber–optic endoscope to visualize the vaporization of nuclear material with a laser, while other devices such as ArthoCare’s claim to perform a “nucleoplasty” by cobla-tion™ of nuclear material. Other devices and manufacturers, for example, Stryker’s Dekompressor™ device, claim to perform a PDD by removing nuclear material.