Basics of CPT code 63052 and 63053

CMS is added new CPT codes for additional decompression when performed with posterior or transforaminal lumbar interbody fusion (PLIF or TLIF). New CPT code 63052 and 63053 describe decompression when done with PLIF or TLIF procedures (22630/32 and 22634/36). 63052 describes the first level decompression and 63053 describes additional levels of decompression. These CPT codes are add-on codes and should not be reported alone and should be coded along with a primary surgery procedure codes, which we will discuss below.

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Description of CPT code 63052 and 63053

+63052 Laminectomy, facetectomy, or foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s] [eg, spinal or lateral recess stenosis]), during posterior interbody arthrodesis, lumbar; single vertebral segment (List separately in addition to code for primary procedure)

+63053 each additional vertebral segment (List separately in addition to code for primary procedure)

CPT Code 63053 should be used in conjunction with 63052.

The physician performs a unilateral or bilateral laminectomy, facetectomy, or foraminotomy of the lumbar spine with decompression of the spinal cord, cauda equina, and/or nerve roots to treat conditions such as spinal or lateral recess stenosis. The procedure is performed in conjunction with posterior interbody fusion of the lumbar spine and is reported separately in addition to that procedure. Following appropriate anesthesia, the patient is positioned face down. Magnification may be used during the procedure. The physician makes a posterior midline incision overlying the affected lumbar vertebrae. Fascia is incised and paravertebral muscles are retracted. If performing a laminectomy, the physician removes the appropriate spinous processes with rongeurs. If the stenosis is central, the physician removes the lamina out to the articular facets using a burr. If the compression is in the lateral recess, only half of the lamina is removed. An elevator peels the ligamentum flavum away from the dura. Nerve root canals may be freed by additional resection of the facet, and compression may be relieved by removal of any bony or tissue overgrowth around the foramen. Removal of the lamina, facets, bony tissue, or overgrowths may be performed bilaterally when indicated. A free-fat graft may be placed over the nerve root(s) for protection. If the ligamentum flavum was spared, it may be placed over the free-fat graft. CPT code 63052 is reported if the procedure is performed on a single vertebral segment; CPT code 63053 is reported for each additional segment.

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CPT code 63052 and 63053 should be reported with Below CPT codes

Since the codes 63052 and 63053 are addon codes, they will need primary cpt codes. Below codes should be coded first or primary codes along with codes 63052 and 63053.

22630 Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace, lumbar;
  
+22632 each additional interspace (List separately in addition to code for primary procedure)
 
22633 Arthrodesis, combined posterior or posterolateral technique with posterior interbody technique including laminectomy and/or discectomy sufficient to prepare interspace (other than for decompression), single interspace, lumbar;
  
+22634 each additional interspace (List separately in addition to code for primary procedure)