Laminectomy is a surgical procedure that removes the lamina - the back part of a vertebra that covers your spinal canal. Read the article to know more about the procedure.

1. Medical Coding for
Laminectomy – A Common
Orthopedic Surgical
Procedure
Laminectomy is a surgical procedure that removes
the lamina - the back part of a vertebra that
covers your spinal canal. Read the article to know
more about the procedure
Outsource Strategies International
United States

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If you happen to experience mild to severe back pain that generally spreads
down to your legs, then it must be a symptom of spinal stenosis. Spinal
stenosis is caused by the narrowing of the spaces within the spinal column
which puts pressure on the spinal cord or nerves. The condition generally
occurs due to the wear and tear changes in the spine and other causes
including herniated disks, thickened ligaments, overgrowth of bone, tumors
and spinal injuries. This spinal disorder is most common in men and women
above 50 years of age. However, it can also occur in younger people who are
born with a narrowing of the spinal canal or who suffer an injury to the
spine. In some cases, the narrowing of the spinal column may heal with
conservative modalities like practicing proper body mechanics, back
exercises, anti-inflammatory medications and physical therapy. However, in
most cases, long-lasting pain relief can be easily achieved through a surgical
procedure known as a “laminectomy”. Laminectomy is a surgical procedure
wherein a surgeon removes part or all of the vertebral bone (lamina – the
back part of a vertebra that covers your spinal canal). This helps ease
pressure on the spinal cord or the nerve roots that may be caused by injury,
herniated disk, narrowing of the canal (spinal stenosis), or tumors. A
laminectomy is considered only after other medical treatments have not
worked. Orthopedic surgeons who perform this procedure need to correctly
document the same in the patient’s medical records. Opting for billing and
coding services from a reputable medical billing and coding outsourcing
company can help simplify the documentation process.
Also known as decompression/lumbar surgery, laminectomy is generally
performed in the cervical and lumbar regions, and less often in the thoracic
region. Bony overgrowths within the spinal canal can narrow the space
available for your spinal cord and nerves. This pressure can cause pain,
weakness or numbness that can radiate down your arms or legs. Generally,
laminectomy is considered a safe procedure. However, as with any type of
surgery, this also involves its own risk of complications and these include –
bleeding, infection, blood clots, nerve injury and spinal fluid leak.
How Is Laminectomy Performed?
Before undergoing the surgical procedure, patients need to provide a
complete medical history to the physicians. This may include information
about any prescription or over-the-counter drugs, vitamins, or supplements
consumed, allergic reactions to any medications, anesthetic agents, tape, or

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latex and pregnancy issues (if any). Before the surgery, the physician may
ask patients to stop consuming blood thinners, (such as aspirin) and stop
the habit of smoking (if he/she is a smoker). In addition, patients may also
be asked not to eat or drink anything after midnight the evening before the
surgery.
Generally, a laminectomy is performed under general anesthesia. The
surgeon will make a small incision or cut in the middle of your back or neck
over the affected vertebrae and move the muscles, skin and ligaments away
from your spine (as needed) to get a better view. The size of the incision
may vary depending on your condition and body size. In most cases,
minimally invasive surgeries typically use smaller incisions than those used
for open procedures. The surgeon may remove the bony arch of the
posterior part of the vertebra (lamina) to ease the pressure on the nerves in
the area. This may involve removing bone spurs or growths, or removing all
or part of a disk.
However, if one vertebra has slipped over another or if the spine suffers a
curvature, spinal fusion may be necessary to stabilize the spine. During a
spinal fusion, the surgeon will connect two or more bones in your spine
using bone grafts and, if necessary, metal rods and screws. In addition, the
surgeon may also perform a foraminotomy to widen the area where the
nerve roots go through the spine. The whole process of laminectony takes
about 1-3 hours. The incisions will be closed with stitches or surgical staples
and a sterile bandage or dressing will be applied.
Removal of either the part or all of the vertebral bone (lamina) is one of the
many procedures that a medical coding and billing company helps orthopedic
surgeons document, code and report. Orthopedic medical billing and
coding is complex as there are several code categories. Orthopedic
specialists performing laminectomy must use the relevant medical codes to
bill for the procedure.
The CPT codes used to report laminectomy procedure include –
 63001 - Laminectomy with exploration and/or decompression of spinal
cord and/or cauda equina, without facetectomy, foraminotomy or
discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; cervical

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 63003 - Laminectomy with exploration and/or decompression of spinal
cord and/or cauda equina, without facetectomy, foraminotomy or
discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; thoracic
 63005 - Laminectomy with exploration and/or decompression of spinal
cord and/or cauda equina, without facetectomy, foraminotomy or
discectomy (e.g., spinal stenosis), 1 or 2 vertebral segments; lumbar,
except for spondylolisthesis
 63015 - Laminectomy with exploration and/or decompression of spinal
cord and/or cauda equina, without facetectomy, foraminotomy or
discectomy (e.g., spinal stenosis), more than 2 vertebral segments;
cervical
 63016 - Laminectomy with exploration and/or decompression of spinal
cord and/or cauda equina, without facetectomy, foraminotomy or
discectomy (e.g., spinal stenosis), more than 2 vertebral segments;
thoracic
 63017 - Laminectomy with exploration and/or decompression of spinal
cord and/or cauda equina, without facetectomy, foraminotomy or
discectomy (e.g., spinal stenosis), more than 2 vertebral segments;
lumbar
 63020 - Laminotomy (hemilaminectomy), with decompression of nerve
root(s), including partial facetectomy, foraminotomy and/or excision of
herniated intervertebral disc; 1 interspace, cervical
 63035 - Laminotomy (hemilaminectomy), with decompression of nerve
root(s), including partial facetectomy, foraminotomy and/or excision of
herniated intervertebral disc; each additional interspace, cervical or
lumbar (List separately in addition to code for primary procedure)
 63040 - Laminotomy (hemilaminectomy), with decompression of nerve
root(s), including partial facetectomy, foraminotomy and/or excision of
herniated intervertebral disc, reexploration, single interspace; cervical
 63045 - Laminectomy, facetectomy and foraminotomy (unilateral or
bilateral with decompression of spinal cord, cauda equina and/or nerve
root[s], [e.g., spinal or lateral recess stenosis]), single vertebral
segment; cervical
 63046 - Laminectomy, facetectomy and foraminotomy (unilateral or
bilateral with decompression of spinal cord, cauda equina and/or nerve
root[s], [e.g., spinal or lateral recess stenosis]), single vertebral
segment; thoracic

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 63048 - Laminectomy, facetectomy and foraminotomy (unilateral or
bilateral with decompression of spinal cord, cauda equina and/or nerve
root[s], [e.g., spinal or lateral recess stenosis]), single vertebral
segment; each additional segment, cervical, thoracic, or lumbar (List
separately in addition to code for primary procedure)
After the surgery, the patient will be directly shifted to a recovery room
wherein they will be closely monitored for any specific complications from
the surgery and anesthesia. Patients will be given pain medications and
antibiotics to reduce pain at the incision site. They will be asked to slowly lift
and move their arms and legs. In some cases, physicians may recommend
physical therapy after a laminectomy to improve strength and flexibility.
Depending on the amount of lifting and walking, patients will be able to
return to work within a few weeks. However, the recovery time will be longer
for patients who had spinal fusion procedure.
Most people may experience visible improvement in their symptoms after
laminectomy, particularly a decrease in pain that radiates down the leg or
arm. However, the procedure does not prevent the occurrence of spine
problems in the future. People who have undergone the procedure need to
take essential preventive steps such as avoiding strenuous activities, heavy
lifting, be careful while climbing stairs and gradually increase the level of
activities like walking as these will prevent the risk of infections.
Knowing the correct medical codes related to laminectomy is critical for
providers. Partnering with an experienced medical billing and coding
company is a great option for physicians to ensure accurate and timely
claim submissions.