Surgical · Spine

Open cervical laminectomy with facetectomy and foraminotomy at a single vertebral level to decompress nerve roots or the spinal cord.

Verified May 8, 2026 · 6 sources ↓

Medicare: $1,249.53
Total RVUs: 37.41
Global, days: 90
Region: Spine

Drawn from CMSMdclarityAAPCMedtronic

Documentation requirements

What must appear in the operative or office note to support the claim.

Source · Editorial brief grounded in 6 cited references ↓

Specify the exact cervical level(s) operated on (e.g., C5-6), not just 'cervical spine'
Name the approach and confirm posterior open technique — audit teams flag notes that say only 'standard approach'
State which neural structures were decompressed and confirm nerve root decompression was performed (supports separate billing from fusion if applicable)
Document each level in a discrete paragraph of the operative note — one paragraph per nerve root decompression level when billing 63048 add-ons
Record findings prompting decompression (e.g., foraminal stenosis, osteophyte, disc fragment) linked to the ICD-10 diagnosis code on the claim
Confirm single-level procedure or justify multiple levels with supporting imaging and clinical findings to support add-on code reporting

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 51 Multiple procedures 59 Distinct service 62 Co-surgeons 78 Unplanned return — related 79 Unrelated during global 80 Assistant surgeon AS PA/NP/CNS assistant LT Left side RT Right side XS Separate structure

What this code covers

Source · Editorial summary grounded in 6 cited references ↓

63045 covers an open posterior cervical decompression in which the surgeon removes part of the lamina (laminectomy), resects or trims the facet joint (facetectomy), and enlarges the neural foramen (foraminotomy) at one cervical level. The combined resection relieves pressure on a nerve root or the cord caused by disc herniation, osteophytes, or hypertrophied ligamentum flavum. This is a single-level primary code; each additional level billed on the same session requires add-on code 63048.

The 90-day global period covers all routine postoperative management through day 90. Any unrelated E/M service in that window needs modifier 79; a related return to the OR for a complication needs modifier 78. If the decompression is performed at the same level as a concurrent arthrodesis, NCCI bundling rules apply — review edits carefully before appending modifier 59 or XS. Per CPT Assistant guidance, nerve root decompression is not considered a component of arthrodesis codes, so separate reporting with modifier 59 is supported when decompressions occur at levels distinct from the fusion level.

Effective January 1, 2026, CMS removed a large block of spine procedures from the Inpatient Only list and added them to the ASC Covered Procedures List, making 63045 now payable in the hospital outpatient and ASC settings. The HOPD and ASC payment differentials are material — see the Site of Service comparison table on this page.

RVU & reimbursement

Component RVUs and Medicare national rate. Actual payment varies by GPCI locality.

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	17.5
Practice expense RVU	13.58
Malpractice RVU	6.33
Total RVU	37.41
Medicare national rate	$1,249.53
Global period	90 days

Payment by site of service

Medicare pays different rates by setting. HOPD typically pays substantially more than ASC for the same procedure.

Source · CMS OPPS Addendum B·ASC HCPCS payment rates·2026

Setting	Medicare rate (national)
Office (PFS non-facility) Procedure performed in physician's office	$1,249.53
HOPD (APC 5114) Hospital outpatient department	$7,413.38
ASC (PI G2) Ambulatory surgical center (freestanding)	$3,695.53

Common denial reasons

The recurring reasons claims for CPT 63045 get rejected.

Source · Editorial brief grounded in CMS NCCI edits, AAOS coding appeals, and cited references ↓

Missing or vague level documentation — operative note says 'cervical' without specifying the vertebral level
NCCI bundling conflict when 63045 is billed same-day with arthrodesis codes at the same level without a valid modifier
Add-on code 63048 billed without the primary code 63045 on the same claim
Global period violation — E/M or procedure billed within 90 days post-op without modifier 24, 78, or 79
Diagnosis code mismatch — ICD-10 code does not support cervical-level pathology or does not reflect the documented clinical indication

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01When do I add 63048 to a claim with 63045?

Bill 63048 once for each additional cervical, thoracic, or lumbar level decompressed beyond the first. Each additional level needs its own documented paragraph in the operative note. 63048 cannot be billed without a primary code (63045, 63046, or 63047) on the same claim.

02Can I bill 63045 with a cervical fusion code on the same day?

Yes, but only if the decompression is at a level distinct from the interbody arthrodesis. Per CPT Assistant (May 2018), nerve root decompression is not a component of arthrodesis codes. Append modifier 59 or XS to 63045 and confirm there is no active NCCI edit pairing these codes before submitting.

03What modifier applies if the patient returns to the OR for a wound dehiscence at the cervical incision site within the global period?

Use modifier 78 — unplanned return to the OR for a complication related to the original procedure. Modifier 79 is for an unrelated procedure during the global; don't invert these.

04Is 63045 now payable in an ASC setting?

Yes. Effective January 1, 2026, CMS added 63045 to the ASC Covered Procedures List. See the Site of Service comparison on this page for the payment differential between HOPD and ASC rates.

05How should laterality be handled for 63045?

63045 is a posterior midline procedure and is not inherently unilateral. Laterality modifiers LT/RT are not standard for this code. However, if your MAC or payer requires them for claim processing, follow their specific guidance — do not append them routinely.

06What ICD-10 codes typically support 63045?

Common supporting diagnoses include cervical disc disorders with radiculopathy (M50.1x), cervical spinal stenosis (M48.02), and cervical spondylosis with radiculopathy (M47.12). The diagnosis must specify the cervical level to match the operative documentation.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

Mira's AI scribe captures the operative level by name (e.g., C5-6), the specific decompressive steps performed (laminectomy extent, facet resection, foraminotomy), which nerve roots were decompressed, and the intraoperative findings driving decompression. That level-specific detail prevents the most common denial trigger — a note that documents a cervical procedure without identifying the vertebral level — and supports separate billing of 63048 when additional levels are addressed.

See how Mira captures CPT 63045 documentation