Mild Coding: Turning to 63030, 63047 Could Trip You Up

Properly reporting minimally invasive lumbar decompression (MILD) procedures with open and endoscopic techniques just got a bit easier. Follow this scenario and coding advice when your neurosurgeon performs a MILD.

Scenario: Through a small incision and using fluoroscopic guidance, the surgeon performs an epidurogram to identify the specific lumbar stenosis location, followed by a small laminotomy and decompressive resection of the ligamentum flavum to treat the patient's central canal spinal stenosis. As a result, should you go for 63030 or 63047 for this procedure?

The answer is no. You would report these services with 'unlisted spine code, or 22899 or 64999, unlisted procedure, nervous system, according to CPT Assistant. The rationale is that the MILD procedure involves a fluoroscopic, needle-based procedure without direct visualization of critical neural structures. MILD procedure devices "aren't intended for disc procedures" but should be used for "tissue resection at the perilaminar space inside the interlaminar space, and at the ventral aspect of the lamina. These devices aren't intended for use near the lateral neutral elements and remain dorsal to the dura using image guidance and anatomical landmarks, states the CPT Assistant.

As such, you wouldn't use code 63030, (Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, including open and endoscopically-aided approaches; 1 interspace, lumbar), "as the MILD procedure is a needle-based approach and isn't intended for removal of disc material versus an open surgical or open with endoscopic-assisted approach (code 63030)," CPT Assistant says.

You'd report 63030 "only when an open surgical technique is used and the intrinsic vital components of this code are carried out; namely, a resection of the vertebral component, spinous processes, and lamina, which must cover a discectomy, for decompression of the nerve root(s), as well as any laminotomy or laminectomy foraminotomy along with partial facetectomy, as required for decompression of the nerves or needed as part of the surgical approach.

Further, CPT Assistant explains that you would not use 63047 (Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [example, spinal or lateral recess stenosis]), single vertebral segment: lumbar) when your surgeon carries out a MILD procedure as code 63047 is only reported if anopen surgical technique is used when the intrinsic components of this code's key elements are carried out, namely a resection of the vertebral component, spinous processes which includes a laminotomy, laminectomy or hemilaminectomy (unilateral or bilateral) lamina, along with foraminotomy with partial facetectomy."

Also considered part of 63047 services are repairs of small dural "lacerations or leaks, and harvesting and placement of soft tissue graft, muscle, or fat when got from within the primary surgical incision" and wouldn't be reported separately.