Question

A 47 year-old male presents with chronic back pain and lower left leg radiculitis. A laminectomy is performed on the inferior end of l5. The microscope is used to perform microdissection. There was a large extradural cystic structure on the right side underneath the nerve root as well as the left. The entire intraspinal lesion was evacuated. What cpt® code(s) is/are reported for this procedure?

Answer 1

The correct codes are 63267 and 69990.

The codes are given based on the lesion if it is intradural or extradural. In our case here it is extradural cystic structure so that is why it ranges between 63265 to 63268.

We also divide the section of spine depending on where the lesion is being located. Code 63267 describes laminectomy which has evacuation of intraspinal lesion which is found in the lumbar spine.

69990 code documents the use of microscope.