Operative note: a 52-year-old man with an L4 to L5 disc herniation undergoes an open posterior approach. The surgeon performs a unilateral laminotomy (hemilaminectomy) with decompression of the nerve root and excision of the herniated disc at a single lumbar interspace. No facetectomy at additional segments and no prior surgery at this level are documented. Which code best reports this procedure?
63020 laminotomy/decompression, single cervical interspace
63030 laminotomy/decompression + discectomy, single lumbar interspace
63042 laminotomy re-exploration, single lumbar interspace
63047 laminectomy + facetectomy/foraminotomy, single lumbar segment- ACPT 63020, laminotomy with decompression, single cervical interspace
- BCPT 63047, laminectomy with facetectomy and foraminotomy, single lumbar segment
- CCPT 63042, laminotomy re-exploration, single lumbar interspace
- DCPT 63030, laminotomy with decompression and discectomy, single lumbar interspace Correct
Why A is wrong: This is the correct family of decompression code but the wrong spinal region; the note describes a lumbar interspace, not a cervical one.
Why B is wrong: It is tempting because it is a lumbar decompression, but the note documents a laminotomy with discectomy, not a laminectomy with facetectomy and foraminotomy.
Why C is wrong: Re-exploration codes require documented prior surgery at the same interspace, which the note explicitly rules out, so this overstates the service.
Why D is correct: This matches the documentation exactly: a unilateral lumbar laminotomy with nerve root decompression and excision of a herniated disc at one interspace.