A patient with lumbar stenosis and neurogenic claudication from L1 through S1 presented for decompressive laminectomy. Central decompressions were completed at T12-L1. The nerve roots at L5-S1 were then decompressed, bilaterally. How should central decompressions of the spinal cord along with decompression of the nerve roots be coded?
All spinal decompressions are not coded the same, and clinically it is more appropriate to classify the nerve roots to the Peripheral Nervous System rather than the Central Nervous System. Code assignment for decompressive spinal surgery would be dependent on the provider’s documentation of what body part is being decompressed. If the spinal cord and the nerve roots are decompressed, assign codes for both release of the nerve root and the spinal cord. A central decompression indicates release of the spinal cord and involves the central part of the spine. Decompression of the lumbar spine from L-4 down indicates release of the nerve roots. Assign the following ICD-10-PCS codes: