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Official Description

Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Endoscopic decompression of the spinal cord and/or nerve root(s) is a minimally invasive surgical procedure aimed at alleviating pressure on the spinal cord or nerve roots caused by various conditions, such as herniated discs or bony overgrowths. This procedure is performed through small incisions using an endoscope, which is a thin, flexible tube equipped with a camera and light source. The endoscopic approach allows for direct visualization of the affected area while minimizing damage to surrounding tissues. Symptoms that may indicate the need for this procedure include local or radiating pain, reduced mobility, and neurologic compromise, which can manifest as weakness, numbness, or tingling in the extremities. The procedure involves several key steps, including the insertion of a needle and guidewire, the use of metal dilating tubes to create access to the spine, and the removal of bony structures and herniated disc material to relieve pressure on the spinal cord and nerves. This technique is particularly beneficial for patients as it typically results in less postoperative pain, quicker recovery times, and a reduced risk of complications compared to traditional open surgical methods.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

Endoscopic decompression of the spinal cord and nerve root(s) is indicated for patients experiencing symptoms related to spinal cord or nerve root compression. The following conditions may warrant this procedure:

  • Local or Radiating Pain - Patients may present with pain that is localized to the back or radiates down the limbs, indicating nerve involvement.
  • Reduced Mobility - Difficulty in movement or limitations in range of motion can be a sign of nerve compression affecting the spinal cord.
  • Neurologic Compromise - Symptoms such as weakness, numbness, or tingling in the extremities may suggest significant pressure on the spinal nerves or cord.

2. Procedure

The procedure for endoscopic decompression of the spinal cord and nerve root(s) involves several critical steps to ensure effective treatment while minimizing tissue damage:

  • Step 1: Preparation and Imaging - The patient is positioned appropriately, and fluoroscopic guidance is utilized to identify the specific interspace that requires intervention. This imaging technique ensures accurate placement of instruments during the procedure.
  • Step 2: Insertion of Needle/Guidewire - A needle and guidewire are inserted through the skin on one side of the midline and advanced to the targeted level of the spine. This step is crucial for establishing a pathway to the affected area.
  • Step 3: Creation of Access - Small incisions are made around the needle/guidewire to facilitate access. Metal dilating tubes of graduated sizes are then passed over the guidewire, gently spreading the soft tissue and muscles away from the vertebrae to create a working channel.
  • Step 4: Insertion of Endoscope - After the guidewire is removed, a hollow metal cylinder is passed over the metal dilator, which is subsequently removed. The endoscope is then inserted through the metal cylinder, allowing the surgeon to visualize the targeted area on a projection screen.
  • Step 5: Nerve Retraction - A nerve retractor is passed down a working channel of the endoscope to gently move the spinal nerve aside, providing access to the bony structures that need to be addressed.
  • Step 6: Decompression - Surgical instruments are introduced through another working channel of the endoscope to perform a laminotomy, which involves the removal of the bony lamina. Additionally, a partial facetectomy is performed to remove facet joints, and a foraminotomy is conducted to clear bone from around the neural foramen. If necessary, a discectomy is performed to remove herniated intervertebral disc material, either partially or completely.
  • Step 7: Closure - Once the decompression is complete, the retracted nerve is allowed to return to its normal position. The endoscope and metal cylinder are removed, allowing the soft tissue to close the incision naturally. The skin may be closed with sutures or staples, or it may be covered with a dressing to protect the surgical site.

3. Post-Procedure

After the endoscopic decompression procedure, patients can expect a recovery period that may vary based on individual circumstances. Post-procedure care typically includes monitoring for any signs of complications, managing pain with prescribed medications, and following specific activity restrictions to promote healing. Patients are often encouraged to engage in physical therapy to aid in recovery and restore mobility. Follow-up appointments are essential to assess the surgical site and ensure that the decompression has effectively alleviated symptoms. It is important for patients to adhere to their healthcare provider's instructions regarding post-operative care and activity levels to optimize recovery outcomes.

Short Descr NDSC DCMPRN 1 NTRSPC LUMBAR
Medium Descr NDSC DCMPRN SPINAL CORD 1 W/LAMOT NTRSPC LUMBAR
Long Descr Endoscopic decompression of spinal cord, nerve root(s), including laminotomy, partial facetectomy, foraminotomy, discectomy and/or excision of herniated intervertebral disc, 1 interspace, lumbar
Status Code Carriers Price the Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 1 - 150% payment adjustment for bilateral procedures applies.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 2 - Payment restriction for assistants at surgery does not apply to this procedure...
Co-Surgeons (62) 2 - Co-surgeons permitted and no documentation required if the two- specialty requirement is met.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Hospital Part B services paid through a comprehensive APC
ASC Payment Indicator Non office-based surgical procedure added in CY 2008 or later; payment based on OPPS relative payment weight.
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P8I - Endoscopy - other
MUE 2
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
51 Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d).
LT Left side (used to identify procedures performed on the left side of the body)
RT Right side (used to identify procedures performed on the right side of the body)
22 Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service.
50 Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
53 Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use).
58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
62 Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.
74 Discontinued out-patient hospital/ambulatory surgery center (asc) procedure after administration of anesthesia: due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74. note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. for physician reporting of a discontinued procedure, see modifier 53.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
80 Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).
82 Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
GC This service has been performed in part by a resident under the direction of a teaching physician
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
SG Ambulatory surgical center (asc) facility service
X2 Continuous/focused services: for reporting services by clinicians whose expertise is needed for the ongoing management of a chronic disease or a condition that needs to be managed and followed with no planned endpoint to the relationship; reporting clinician service examples include but are not limited to: a rheumatologist taking care of the patient's rheumatoid arthritis longitudinally but not providing general primary care services
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
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2017-01-01 Added Added
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