Fusion · Spine

Partial or complete lumbar vertebral body resection via lateral extracavitary approach, single segment, with spinal cord and/or nerve root decompression.

Verified May 8, 2026 · 7 sources ↓

Medicare: $2,174.06
Total RVUs: 65.09
Global, days: 90
Region: Spine

Drawn from CMSAAPCFindacodeHealthcareinspiredllcFiles

Documentation requirements

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

Source · Editorial brief grounded in 7 cited references ↓

Specify the approach by name: lateral extracavitary — operative notes that reference only 'posterior approach' or 'standard approach' will flag on audit.
Document the lumbar level(s) treated and confirm only one segment is billed per unit of 63102.
Clearly state the pathology driving resection: tumor, metastatic lesion, retropulsed fracture fragments, or other structural diagnosis with supporting imaging.
If co-surgeons are used, each surgeon's operative note must document their distinct, separately identifiable portion of the procedure to support modifier 62.
Document the extent of vertebral body resection (partial vs. complete) and the neural elements decompressed (spinal cord, specific nerve roots).
If fusion or instrumentation is performed at the same session, the operative note must describe each as a separately performed procedure with independent medical necessity.

Applicable modifiers

Modifiers commonly billed with this code.

Source · AMA CPT modifier descriptors · CMS NCCI Policy Manual

22 Increased complexity 51 Multiple procedures 52 Reduced services 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

What this code covers

Source · Editorial summary grounded in 7 cited references ↓

CPT 63102 covers resection of a lumbar vertebral body — partial or complete — performed through a lateral extracavitary approach, a single posterior-based corridor that passes beneath the paraspinal muscles to reach the anterior and lateral vertebral column without a separate thoracic or abdominal incision. The approach allows direct visualization of the vertebral body for decompression of the spinal cord and nerve roots, typically in the setting of tumor, metastatic disease, or retropulsed fracture fragments causing neural compromise. Only one lumbar segment is captured per unit of 63102; each additional thoracic or lumbar segment requires add-on code +63103.

This is a high-complexity procedure with a 90-day global period. Co-surgeon scenarios are common — when two surgeons (e.g., neurosurgery and orthopedic spine) each perform distinct, documented portions of the procedure, modifier 62 applies. If arthrodesis is performed at the same session, report the appropriate fusion code (e.g., 22558) with modifier 51; reconstruction add-ons such as 22845 for instrumentation and 20931/20936 for grafts are commonly appended. Payers will scrutinize same-day bundling aggressively — each companion code needs its own operative note justification.

RVU & reimbursement

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

Source · CMS Physician Fee Schedule, RVU26A · January 2026

Work RVU	33.25
Practice expense RVU	20.28
Malpractice RVU	11.56
Total RVU	65.09
Medicare national rate	$2,174.06
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	$2,174.06

Common denial reasons

The recurring reasons claims for CPT 63102 get rejected.

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

Operative note describes approach generically ('posterior' or 'standard') without naming lateral extracavitary — payers deny for insufficient specificity.
63102 billed for multiple segments without add-on code 63103 for each additional segment, triggering MUE or unbundling edits.
Modifier 62 applied without both surgeons submitting individual operative reports documenting their distinct portions of the procedure.
Same-day fusion or instrumentation codes denied as bundled into 63102 when not supported by separate documentation of independent procedures.
Medical necessity denial when diagnosis coding does not match a condition consistent with vertebral body resection — mismatched or nonspecific ICD-10 codes are the top trigger.

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01What is the difference between 63101, 63102, and 63103?

63101 is for a thoracic single segment via lateral extracavitary approach. 63102 is for a lumbar single segment via the same approach. 63103 is the add-on code for each additional thoracic or lumbar segment — list it separately in addition to 63101 or 63102, never as a standalone code.

02When does modifier 62 apply to 63102?

Use modifier 62 when two surgeons each function as primary surgeons performing distinct, documented portions of the lateral extracavitary corpectomy. Both surgeons append modifier 62 to 63102, and each must submit a separate operative report describing their specific work. Without separate reports, payers will deny the second surgeon's claim.

03Can you bill arthrodesis and instrumentation same-day as 63102?

Yes, if performed and separately documented. A common construct is 63102 + 22558 (anterior interbody lumbar fusion) with modifier 51 + 22845 (anterior instrumentation) + 20931 or 20936 (grafts, no modifier 51). Each code needs operative note support. Check your payer's NCCI edits before submitting — bundling rules vary.

04What diagnoses typically support medical necessity for 63102?

Primary and metastatic spinal tumors, severe vertebral fractures with retropulsed bone fragments causing neural compression, and advanced degenerative or destructive vertebral disease unresponsive to conservative management. A nonspecific or symptom-only ICD-10 code without an identifiable structural lesion is the leading cause of medical necessity denial for this code.

05Is 63102 used for endoscopic or minimally invasive lateral corpectomy?

No. 63102 specifically describes the open lateral extracavitary approach. Minimally invasive or endoscopic variants may require different or unlisted codes. Confirm the operative technique maps to the open lateral extracavitary corridor before billing 63102 — approach mismatch is an audit risk.

06What is the global period for 63102, and what does it cover?

63102 carries a 90-day global period. That covers the surgery, the day-before pre-op visit, and all routine post-op care through day 90. Unrelated E/M services in that window require modifier 24; a new problem requiring a separately identifiable E/M on the day of surgery needs modifier 25 on the pre-op encounter.

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 approach name (lateral extracavitary), the lumbar level treated, the pathology (tumor, fracture fragments, or degenerative disease), extent of vertebral body resection (partial or complete), neural elements decompressed, and whether a co-surgeon was present with their distinct procedural role. This prevents the most common audit flag for 63102 — an operative note that documents outcome without specifying approach and extent — and ensures modifier 62 is defensible if two surgeons are billing.

See how Mira captures CPT 63102 documentation