The procedure performed is a posterior laminectomy with facetectomy and foraminotomy for decompression at two cervical levels (C5-C6 and C6-C7). CPT® code 63045 accurately describes this procedure for a single vertebral segment in the cervical region. The code descriptor includes laminectomy, facetectomy, and foraminotomy for decompression. Since the procedure was performed on a second, contiguous segment (C6-C7), the add-on code +63048 is reported for the additional segment. The term "bilateral" in the report is inherent to the code description for 63045, so modifier 50 is not required.

B. 63040-50, 63043, 63043: CPT® 63040 is for a laminotomy (hemilaminectomy), which is a less extensive procedure than the laminectomy performed.

C. 63050-50: CPT® 63050 describes a laminoplasty, a reconstructive procedure where the lamina is hinged open, not a laminectomy where the lamina is removed.

D. 63015: This code is for a laminectomy for decompression without facetectomy or foraminotomy, which contradicts the procedures documented in the operative report.

1. American Medical Association. (2023). CPT® 2024 Professional Edition.

Page 488

Code 63045: "Laminectomy

facetectomy

and foraminotomy (unilateral or bilateral with decompression of spinal cord

cauda equina and/or nerve root[s]

[eg

spinal or lateral recess stenosis])

single vertebral segment; cervical." This description matches the primary procedure.

Page 488

Code +63048: "...each additional segment

cervical

thoracic

or lumbar (List separately in addition to code for primary procedure)." The parenthetical note states

"Use 63048 in conjunction with 63045

63046

63047

" confirming its use for the second segment.

2. AAPC. (2023). 2024 CPC Official Study Guide. Chapter 11: Musculoskeletal System.

The section on Spine and Spinal Cord surgery explains that when a laminectomy includes facetectomy and foraminotomy for decompression

codes from the 63045-63048 series are used. It clarifies that 63045 is the base code for the first segment and +63048 is the add-on code for each additional segment.