0 code page views remaining today. Guest accounts are limited to 2 daily page views. Register free account to get more views.
Log in Register free account

Official Description

Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Laminectomy, also known as lamina excision, is a surgical procedure aimed at alleviating back pain and addressing issues related to spinal cord compression. This procedure specifically targets the lamina, which is the bony structure forming the posterior part of the vertebral arch. By removing the lamina, the surgeon can relieve pressure on the spinal cord, spinal nerve roots, and/or cauda equina, which may be causing symptoms such as pain, weakness, or numbness. The procedure typically begins with a posterior skin incision made over the affected area of the spine, allowing access to the underlying structures. Once the incision is made, the surgeon retracts the overlying fat and muscle to expose the lamina. The excision of the lamina is followed by the removal of the paired ligaments, known as the ligamentum flavum, that connect adjacent vertebrae. This step is crucial for exposing the spinal canal, where the spinal cord and nerve roots reside. During the procedure, the surgeon may also address any adhesions between the dura mater and the ligamentum flavum, ensuring that the spinal nerve roots and cauda equina are carefully dissected and freed from any compressive elements. This procedure can be performed on one or two contiguous vertebral segments, depending on the extent of the spinal stenosis or other underlying conditions. It is important to note that if additional stabilization of the spine is required, a separate arthrodesis procedure may be performed. The specific code for reporting laminectomy of one or two cervical vertebral segments is 63001, while different codes are designated for thoracic, lumbar, and sacral spine procedures.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The laminectomy procedure is indicated for various conditions that lead to spinal cord or nerve root compression. The following are the explicitly provided indications for performing this procedure:

  • Spinal Stenosis - A narrowing of the spinal canal that can cause pressure on the spinal cord and nerves, leading to pain and neurological symptoms.
  • Back Pain - Chronic or severe back pain that may be attributed to nerve compression or other spinal issues.
  • Cauda Equina Syndrome - A serious condition resulting from compression of the cauda equina, which can lead to significant neurological deficits.

2. Procedure

The laminectomy procedure involves several critical steps to ensure effective decompression of the spinal cord and nerve roots. The following procedural steps are outlined:

  • Step 1: Incision - A posterior skin incision is made over the affected segment of the spine. This incision allows the surgeon to access the underlying vertebrae and associated structures.
  • Step 2: Retraction - The overlying fat and muscle tissues are carefully retracted to expose the lamina. This step is essential for providing a clear view of the surgical field and the lamina that needs to be excised.
  • Step 3: Lamina Excision - The lamina is excised to relieve pressure on the spinal cord and nerve roots. This involves cutting through the bony structure of the lamina, which is crucial for alleviating symptoms associated with spinal stenosis.
  • Step 4: Ligament Removal - The paired ligaments, known as the ligamentum flavum, that connect adjacent vertebrae are also excised. This step further opens the spinal canal and allows for better access to the spinal cord and nerve roots.
  • Step 5: Exploration and Lysis of Adhesions - The spinal canal is explored, and any adhesions between the dura mater and the ligamentum flavum are lysed. This is important for ensuring that the spinal cord and nerve roots are free from any constrictive bands that could impede recovery.
  • Step 6: Dissection of Nerve Roots - The spinal nerve roots and/or cauda equina are carefully dissected and freed within the intervertebral foramen. This step is critical for relieving any compression that may be causing pain or neurological symptoms.
  • Step 7: Stabilization (if needed) - If the procedure indicates a need for stabilization, a separate arthrodesis may be performed to ensure the spine remains stable post-surgery.

3. Post-Procedure

After the laminectomy procedure, patients can expect a recovery period that may vary based on individual circumstances and the extent of the surgery. Post-procedure care typically includes monitoring for any complications, managing pain, and beginning rehabilitation exercises as advised by the healthcare provider. Patients may be instructed to avoid certain activities that could strain the spine during the initial recovery phase. Follow-up appointments are essential to assess healing and determine if additional interventions, such as physical therapy, are necessary to support recovery and improve mobility.

Short Descr REMOVE SPINE LAMINA 1/2 CRVL
Medium Descr LAM W/O FACETEC FORAMOT/DSC 1/2 VRT SGM CRV
Long Descr Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy (eg, spinal stenosis), 1 or 2 vertebral segments; cervical
Status Code Active 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) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
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) P1F - Major procedure - explor/decompr/excis disc
MUE 1
CCS Clinical Classification 3 - Laminectomy, excision intervertebral disc

This is a primary code that can be used with these additional add-on codes.

22840 Addon Code MPFS Status: Active Code APC N ASC N1 Physician Quality Reporting CPT Assistant Article Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)
22841 Addon Code MPFS Status: Bundled Code APC C Physician Quality Reporting CPT Assistant Article Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)
22842 Addon Code MPFS Status: Active Code APC N ASC N1 Physician Quality Reporting CPT Assistant Article Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)
22843 Addon Code MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 7 to 12 vertebral segments (List separately in addition to code for primary procedure)
22844 Addon Code MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 13 or more vertebral segments (List separately in addition to code for primary procedure)
22845 Addon Code MPFS Status: Active Code APC N ASC N1 Physician Quality Reporting CPT Assistant Article Illustration for Code Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)
22846 Addon Code MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Anterior instrumentation; 4 to 7 vertebral segments (List separately in addition to code for primary procedure)
22847 Addon Code MPFS Status: Active Code APC C Physician Quality Reporting CPT Assistant Article Illustration for Code Anterior instrumentation; 8 or more vertebral segments (List separately in addition to code for primary procedure)
22848 Addon Code MPFS Status: Active Code APC N Physician Quality Reporting CPT Assistant Article Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)
22853 CPT Add On MPFS Status: Active Code APC N ASC N1 Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure)
22854 CPT Add On MPFS Status: Active Code APC N ASC N1 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
22859 CPT Add On CPT Resequenced MPFS Status: Active Code APC N ASC N1 Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh, methylmethacrylate) to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure)
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).
GC This service has been performed in part by a resident under the direction of a teaching physician
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.
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
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.
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.
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.
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).
81 Minimum assistant surgeon: minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.
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)
ET Emergency services
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
LT Left side (used to identify procedures performed on the left side of the body)
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
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2022-01-01 Note Medium description changed.
2013-01-01 Note Short Descriptor changed.
2008-01-01 Changed Code description changed.
2007-01-01 Changed Code description changed.
Pre-1990 Added Code added.
Code
Description
Code
Description
Code
Description
Code
Description