CPT Knowledgebase - Oct 25, 2019

A surgeon performed a left L3-L4 facetectomy, foraminotomies, and resection of a sequestered disc fragment. The surgeon placed a spinal needle in the paravertebral musculature on the right side, under fluoroscopic guidance, in order to identify the level of the L3-L4 disc space and facet. The surgeon then removed the spinal needle, made a midline incision, extended the incision down to the scarred lumbodorsal fascia, and dissected this out laterally toward the facet at L3-L4. After encountering the facet, the surgeon placed a marker and obtained a lateral fluoroscopic image to confirm placement in the disc space at L3-L4. Then the surgeon thinned down the facet with a high-speed drill and removed it using Kerrison rongeurs. The surgeon identified the L3 nerve root superiorly and in its axilla found two sizable sequestered disc fragments. After removing them, the surgeon decompressed the overlying nerve root, inspected the disc space itself, and found no additional fragments. Which CPT code (63030 or 63056) should be reported for the described scenario?

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