63048 Clarification

Question:

Hello! My question is regarding CPT coding. Is CPT 63048 an add-on to 63052?

Example: L3-L4 TLIF w/ Laminectomy, L4-L5 Posterior Instrumentation Fusion w/ Laminectomy.

Would this be coded as:

• 22633, 22614, 63052, 63047

OR

• 22633, 22614, 63052, 63048

Answer:

CPT code 63048 is an add-on code to be used in conjunction with CPT codes 63045, 63046, and 63047 – not with 63052.

Based on the scenario, and provided the documentation supports reporting decompression at both levels/interspaces, the appropriate coding would be:

• 63052 for the interbody level (TLIF at L3/L4)

• 63047 for decompression at L4/L5

Thank you for reaching out to KZA with your inquiry.

*This response is based on the best information available as of 06/04/26.

ALIF via Retroperitoneal Approach

Question:

I have been researching the coding for ALIF via retroperitoneal approach, and my research points to 22558 or an unlisted spine code; however, my provider states it should be CPT 22533. Can you please help?

Answer:

Thank you for your question!

CPT 22533, as suggested by your provider, refers to a lateral extracavitary arthrodesis (LECA), which is an anterior fusion performed from a posterior approach.

A CPT Assistant from October 2009 discusses the lateral extracavitary (LECA) approaches to the lumbar spine and explains how to differentiate LECA from other approaches.

For an anterior lumbar interbody fusion (ALIF) performed via a retroperitoneal approach, the correct CPT code is 22558.

*This response is based on the best information available as of 05/07/26.

Mod 62 & Spinal Instrumentation

Question:

Our coding department has a question. Due to the high complexity of the case, two surgeons from different specialties (an orthopedic surgeon and a neurosurgeon) completed the surgery together. Can modifier 62 be applied to spinal instrumentation codes?

Answer:

Although two surgeons from different specialties were involved in this complex case, modifier 62 cannot be appended to spinal instrumentation codes.

CPT guidelines specifically state: “Do not append modifier 62 to spinal instrumentation codes (22840–22848, 22850, 22852, 22853, 22854, 22859).”

Modifier 62 (Two Surgeons) applies only when each surgeon performs distinct, separate portions of the same procedure, and each surgeon must document their specific portion in separate operative reports.  

Example: For an ALIF, if a general or vascular surgeon performs the approach and closure, while a spine surgeon performs the interbody procedure…

• Both surgeons would document their respective portions of the operative service.

• Both would report CPT 22558‑62.

• This meets CPT criteria for true co‑surgery. 

If the second surgeon is participating specifically in the placement of spinal instrumentation, consideration should be given to whether an assistant‑at‑surgery modifier (80 or 82) may be appropriate, since modifier 62 is not allowed on instrumentation codes.

*This response is based on the best information available as of 04/02/26.

Osteotomy & Laminectomy Same Level

Question:

I have a question about a complicated surgery and was hoping to get some feedback, as I've been receiving mixed responses and want to ensure these procedures are being reported accurately. Am I able to report any laminectomy that overlaps at the same levels as spinal osteotomies?

Answer:

Great question! Spinal osteotomy is performed to correct spinal deformity and includes laminectomy and decompression at the same level. Because these components are considered inherent to the osteotomy procedure, it is not appropriate to report the laminectomy separately at the same level.

To ensure accurate coding, the operative report should clearly document:

• The type of spinal deformity

• The degree of correction being sought by osteotomy

• Details of how the osteotomy was performed

• The resulting changes from osteotomy

 If the documentation supports spinal osteotomy, it encompasses the laminectomy at that level.

 Thank you for reaching out to KZA with your inquiry.

*This response is based on the best information available as of 03/05/26.

Coding 61750 vs. 61751 for a Stereotactic Biopsy

Question:

We struggle with the code description for CPT 61750 vs 61751. Our providers load MRI and/or CT scans to a stereotactic navigation machine during surgery for Stereotactic biopsy, aspiration, or excision of a tumor. Which code would be correct when an MRI scan is used during surgery? The scan was done prior to going to the OR.

Answer:

Code 61751 is reported regardless of when the CT was performed, and it is typically performed before the patient goes to the OR.

*This response is based on the best information available as of 02/07/26.

Coding Clarification: Instrumentation Removal vs. Exploration Based on Intent

Question:

Good afternoon,

I recently came across one of your Q&As from June 2025 that stated when spinal instrumentation is removed for the purpose of exploration, we would code the exploration CPT code 22830. This is helpful information; however, I am wondering if you can provide a reference for this. I would love to pass this information along to our providers, and a solid source would help to support it.

Answer:

In June 2025, the coding question was clarified:

CPT code 22830 should be billed if the intent for the procedure was for exploration.

If the intent is to explore the spinal fusion site, and instrumentation is removed only to allow that exploration, then CPT 22830 is reported. If the true intent is to remove the instrumentation (e.g., due to pain, infection, or hardware failure), and exploration is incidental, then only the instrumentation removal code is reported.

The National Correct Coding Initiative (NCCI) bundles certain codes based on the principle of standards of medical/surgical practice, which means: If a service is routinely performed as part of another procedure, it is considered integral and not separately reportable.

*This response is based on the best information available as of 01/22/26.