Picture this scenario: Dr. Smith’s neurosurgery practice just received another denial for a lumbar decompression procedure. The billing team is confused about the denial and can’t find the reason, because they filed everything perfectly. The documentation seemed complete, the procedure was medically necessary, yet the reimbursement never came through.
Does this sound familiar to you? Well, you are not alone. This happens more commonly than you think. CPT code 63047 is frequently used in neurosurgery but often misunderstood. That’s why we decided to create this comprehensive guide on 63047.
By the end of this guide, you will know exactly what to do with your 63047 claim, if you are faced with one. So, let’s start.
CPT Code 63047 – Description
CPT code 63047 refers to:
“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; lumbar.”
Confused? Let’s break this down in simpler terms.
Code 63047 is a neurosurgery billing code used for comprehensive lumbar spine surgery involving the cauda equina and nerve roots. This code encompasses three procedures: laminectomy (removal of the lamina), facetectomy (removal of the facet joint), and foraminotomy (widening of the nerve root exits). The code applies to the treatment of a single vertebral segment only. For procedures involving multiple vertebrae, use the appropriate alternative codes.
The surgery is performed to relieve pressure on the spinal nerves in the lumbar region. As a result of this surgery, the patient experiences less pain, numbness, and weakness in the legs.
An important point to note here is that CPT code 63047 has a Bilateral Surgery Status Indicator “2”. This means that the code should not be billed with modifier 50 or other unilateral (LT/RT) modifiers, as it is already considered a bilateral procedure.
Scenarios Where CPT Code 63047 is Applicable
The description may not be enough to clear the confusion. So, let’s discuss a couple of real-world scenarios in which CPT code 63047 can be used:
Lumbar Spinal Stenosis
Suppose a patient visits a neurologist. He shares that for the past few weeks, he has been experiencing severe lower back pain and leg weakness that worsens when walking. He is also experiencing numbness in both legs and can’t even stand for long periods. These symptoms suggest lumbar spinal stenosis.
The only permanent treatment option is surgery. So, the physician performs a laminectomy at L4-L5 to decompress the spinal canal. During the same surgical session, the surgeon also removes a portion of the facet joint at the same lumbar level to relieve further compression. In this scenario, the entire surgical procedure can be billed with CPT code 63047.
Nerve Root Compression Due to Spinal Stenosis
Let’s consider another scenario.
A 70-year-old patient with a history of osteoarthritis presents to the clinic with pain extending down the left leg, accompanied by muscle weakness and numbness. The neurologist suspects nerve root compression caused by spinal stenosis. This is confirmed via various tests (X-rays and MRIs).
The physician performs a laminectomy, facetectomy, and foraminotomy, all on one lumbar vertebra, to decompress the affected nerve root. Finally, the medical billing department codes and submits the claim for reimbursement. In this case, CPT code 63047 is used.
Applicable Modifiers for CPT Code 63047
Depending on the situation, you may append the following modifiers with CPT code 63047 to justify the billed amount on your claims.
| Modifier | Short Description | When to Use |
|---|---|---|
| 52 | Reduced Service | Used when the procedure is partially reduced or eliminated. |
| 59 or XS | Distinct Procedural Service | When CPT 63047 is performed at a different interspace than CPT 22630 or 22633. |
| 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. |
| 81 | Minimal Assistant Services | When the assistant surgeon’s services are minimal during the surgery. |
| AS | PA/NP/CNS Assistant | When a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) assists at surgery. |
CPT Code 63047 – Billing & Reimbursement Guidelines
Knowing the details is not enough to guarantee successful reimbursement. You must also be aware of essential billing guidelines and code limitations. The following are some vital things to keep in mind while filing claims for CPT code 63047:
Provide Detailed Documentation
Payers require detailed documentation to process the claims. Without comprehensive documentation, medical records, and a clinical indication that justifies the procedure, your claims will be rejected. For 63047, you should always provide the following details:
- Detailed patient symptoms
- Physical examination findings and any imaging results (MRI, X-rays, and others)
- Any prior medications
- Clinical notes
- Prescribed medicines
- Any complications encountered during surgery
Keep in Mind the Global Surgery Period
CPT code 63047 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. The reimbursement division percentage for pre-operative, intra-operative, and post-operative services is:
- 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 amount for CPT code 63047 varies based on MAC locality and the specific part of the procedure (pre-, intra-, and post-operative).
Medicare’s national average reimbursement for 63047 in facility settings is $1,094.93. You can check the exact amount for your MAC locality via the PFS Lookup Tool.
Be Wary of the Limitations
The CMS NCCI Policy Manual prohibits billing CPT 63047 with posterior lumbar interbody fusion codes (22630, 22633) at the same interspace.
However, you can separately bill 63047 if both procedures are performed at different vertebral interspaces. In this case, you will have to bill 63047 with modifier 59 or XS.
Wrapping Up
Neurosurgery codes are hard to master. Small mistakes lead to claim denials and lost revenue. CPT code 63047 has a high reimbursement amount, and its denial can significantly affect your cash flow. For proper reimbursement, follow the guidelines provided in the blog.
However, even after following billing guidelines and carefully submitting claims, denials can occur. To avoid them, it is better to get professional neurosurgery billing services from a third-party company like MediBillMD.
