Do you know that radiculopathy due to lumbar disc herniations is diagnosed in almost 5% of all lower back pain patients? That’s a significant number. Usually, the ailment is treated via conservative treatments. However, it may also require surgery.
In most cases, the performed surgical procedure is billed via CPT code 63030. This makes 63030 a commonly used procedure code in neurosurgery billing. We have created this guide to help clear up any confusion around this vital code.
So, without any further ado, let’s start.
CPT Code 63030 – Description
CPT code 63030 is defined as:
“Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar.”
Sounds hard? Let us explain this in simple terms.
Code 63030 is a spinal surgery code for the lower back (lumbar region, L1-L5). During the surgery, the physician removes a small portion of bone from one side of the spine to relieve pressure on pinched nerves.
Typically, several surgical techniques are performed simultaneously. The following is a brief description of all the main surgical steps:
- Laminotomy (hemilaminectomy): Trimming back part of the lamina (bone covering the spinal canal).
- Facetectomy: Removing part of the spinal facet joint to relieve pressure on a compressed spinal nerve root.
- Foraminotomy: Widening the foramen (nerve exit holes).
- Removing herniated disc material pressing on nerves (optional).
Please note that this code is used only for lumbar spinal surgeries. Also, the procedure under CPT code 63030 is limited to a single interspace, which is the space between two vertebrae.
Scenarios Where CPT Code 63030 is Applicable
Still not clear how to use CPT code 63030? The following are some real-world cases that might help you understand the details.
Disc Disorders with Radiculopathy
Let’s suppose that a patient visits a neurosurgeon. He shares that he has been feeling sharp, shooting pain that travels from the lower back down through the right leg. The patient also shares that he has been taking common painkillers for the past two months, but the pain is getting worse every day. A week ago, he started feeling tingling and numbness in his foot. The patient mentions that sitting makes the pain unbearable and that he is having trouble sleeping at night.
The physician orders an imaging test, which shows a disc problem in the lower spine. To be exact, a displaced disc material is pressing on the nerve roots. After trying physical therapy and medications without improvement, surgery becomes necessary. The surgeon performs a laminotomy at the L5-S1 level to access the affected area. The surgeon then removes the herniated portion of the disc that’s compressing the nerve root, relieving the pressure causing the radiating pain.
In this scenario, the surgical procedure can be billed with CPT code 63030.
Disc Herniation
To clear out any confusion, let’s consider another scenario. Suppose a 45-year-old man visits an orthopedist. He complains of severe lower back pain that started after lifting heavy boxes at work. The pain radiates down the left leg, and the patient describes it as a burning sensation. The physician performs an MRI scan, which clearly shows a herniated disc.
The physician refers the patient to a neurosurgeon. The surgeon suggests and performs a laminotomy at L4-L5 to create an opening to reach the herniated disc. The protruding disc material pressing against the spinal nerve is carefully removed to decompress the nerve.
In this scenario, the entire surgical procedure can be billed with CPT code 63030.
Applicable Modifiers for CPT Code 63030
CPT code 63030 is high-paying. So, insurance carriers pay special attention to claims. To get fair reimbursement for your 63030 claims, you must append appropriate modifiers to your claims that clearly explain the circumstances in which the surgery was performed. The following are the most commonly used modifiers with code 63030:
| Modifier | Description | Usage Scenario |
|---|---|---|
| LT | Left Side | When the surgery is performed on the left side. |
| RT | Right Side | Used when the surgery is performed on the right side. |
| 50 | Bilateral Procedure | Used when surgery is performed on both sides. |
| 54 | Intraoperative Percentage | Applied when only intraoperative services are performed. |
| 55 | Postoperative Percentage | Modifier 55 is used when reimbursement for only postoperative services is required. |
| 56 | Preoperative Percentage | This modifier is applied when billing for preoperative services. |
| 59 | Distinct Procedural Service | Used when the surgery is distinct and separate from other services performed on the same day. |
| 62 | Co-surgery | When two surgeons each independently perform different portions of the surgery simultaneously. |
| 80 | Assistant Surgeon | When an assistant surgeon provides services during the surgery. |
CPT Code 63030 – Billing & Reimbursement Guidelines
Sometimes, small mistakes can lead to claim denials. Yes, we have discussed what CPT code 63030 is, when to use it, and which modifiers to append, but what about the minor details? Well, here are some points that you should consider while filing 63030 claims:
Provide Detailed Documentation
Comprehensive documentation is the key to successful 63030 billing. You must submit relevant documents and patient records to justify medical necessity and ensure reimbursement. Hence, the following details must be included in your claims:
- Documented proof that at least six weeks of conservative treatment were performed before opting for surgery.
- Patient symptoms
- Prescribed medications
- Imaging test results
- Any complications during the surgery
Keep in Mind the Global Surgery Period
CPT code 63030 has a global surgery period of 90 days. So, all the pre- and post-operative services are included in the reimbursement. Do not bill these services separately. Here’s how the reimbursement is divided among the three components:
- Pre-OP: 0.11 (11% of the total payment)
- Intra-OP: 0.76 (76% of total payment)
- Post-OP: 0.13 (13% of the total payment)
Verify Reimbursement Rate
The reimbursement rate for code 63030 varies for each payer and MAC locality. However, Medicare’s national average reimbursement amount in facility settings is $907.64.
You can check the exact amount for your MAC locality via the PFS Lookup Tool.
Wrapping Up
There you have it – the complete guide on CPT code 63030! Billing this code can be tricky. We hope that by following the guidelines we provided in this blog, you can significantly decrease your denial rates.
If your practice is struggling with revenue leaks or facing frequent denials, our team at MediBillMD can help. We offer expert neurosurgery billing services that can supercharge your collections.
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