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Official Description

Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, cervical

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

The procedure described by CPT® Code 63275 involves a laminectomy performed specifically for the biopsy or excision of an intraspinal neoplasm located in the extradural space of the cervical region. An intraspinal neoplasm refers to a tumor that can be either benign, malignant, or of uncertain behavior, which means its potential for growth and spread is not clearly defined. In this surgical intervention, the neoplastic tumor is situated outside the dura mater, the protective membrane surrounding the spinal cord. The procedure begins with an incision made in the skin over the cervical area, where the tumor is identified. The surgical approach requires careful dissection to expose the lamina, which is the bony structure of the vertebrae, and the facet joint. A bone drill is utilized to remove part or all of the lamina, allowing access to the spinal cord and the tumor itself. Once the tumor is located, the surgeon assesses its extent to confirm that it is confined to the extradural tissue. A biopsy may be performed to obtain a tissue sample for pathological examination, which is crucial for determining the nature of the tumor. If the tumor is deemed excisable, the surgeon meticulously dissects it from the surrounding tissues, often using an operating microscope for precision. The procedure concludes with either the closure of the surgical site or the complete removal of the tumor, depending on the findings during the operation.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The procedure is indicated for the evaluation and treatment of intraspinal neoplasms that are located in the extradural space of the cervical region. The following conditions may warrant a laminectomy for biopsy or excision:

  • Intraspinal Neoplasm A tumor that may be benign, malignant, or of uncertain behavior, requiring surgical intervention for diagnosis or treatment.
  • Symptoms of Compression Patients may present with neurological symptoms due to compression of spinal structures, necessitating the removal of the tumor.
  • Diagnostic Uncertainty When imaging studies suggest the presence of a neoplasm, a biopsy may be required to determine the nature of the tumor.

2. Procedure

The laminectomy procedure for biopsy or excision of an extradural intraspinal neoplasm follows several critical steps:

  • Step 1: Incision The procedure begins with a surgical incision made over the cervical region where the tumor is located. This incision allows access to the underlying structures of the spine.
  • Step 2: Exposure The incision is extended down to the spinous processes, and the surrounding muscle is carefully retracted away from the lamina and facet joint to provide a clear view of the surgical field.
  • Step 3: Laminectomy A bone drill is employed to remove part or all of the lamina, which is the bony arch of the vertebra. This step is crucial for exposing the spinal cord and the tumor.
  • Step 4: Tumor Identification Once the spinal cord is exposed, the surgeon identifies the tumor and assesses its extent, confirming that it is limited to the extradural tissue.
  • Step 5: Biopsy or Excision A tissue sample may be obtained for pathology examination. If the tumor is determined to be excisable, the surgeon carefully dissects it away from the surrounding tissue, often using an operating microscope for enhanced visualization.
  • Step 6: Closure After the tumor is completely excised, or if only a biopsy is performed, the surgical site is closed appropriately to promote healing.

3. Post-Procedure

Post-procedure care involves monitoring the patient for any complications related to the surgery, such as infection or neurological deficits. Patients may experience pain at the surgical site, which can be managed with appropriate analgesics. Follow-up appointments are essential to assess the surgical site and review pathology results from the biopsy. Rehabilitation may be recommended to aid recovery and restore function, depending on the extent of the surgery and the patient's overall condition.

Short Descr BX/EXC XDRL SPINE LESN CRVL
Medium Descr LAMINECTOMY BX/EXC ISPI NEO XDRL CERVICAL
Long Descr Laminectomy for biopsy/excision of intraspinal neoplasm; extradural, 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) 1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Inpatient Procedures, not paid under OPPS
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE 1
CCS Clinical Classification 9 - Other OR therapeutic nervous system procedures

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)
63295 Addon Code MPFS Status: Active Code APC C Osteoplastic reconstruction of dorsal spinal elements, following primary intraspinal procedure (List separately in addition to code for primary procedure)
69990 Addon Code MPFS Status: Restricted APC N ASC N1 PUB 100 CPT Assistant Article 1Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure)
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.
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).
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.
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.)
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)
AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
GC This service has been performed in part by a resident under the direction of a teaching physician
GW Service not related to the hospice patient's terminal condition
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
RT Right side (used to identify procedures performed on the right side of the body)
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
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2013-01-01 Changed Short Descriptor changed.
Pre-1990 Added Code added.
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