Summary & Overview
CPT 62331: Lumbar decompression with laminotomy and partial ligamentum flavum removal
Headline: CPT code 62331: Bilateral lumbar laminotomy with partial removal of the ligamentum flavum, with imaging guidance
Lead: CPT code 62331 designates a bilateral add‑on surgical service for lumbar decompression that combines laminotomy, partial resection of the ligamentum flavum, epidurography, and imaging guidance. It is used when additional lumbar interspaces require decompression after the primary interspace has been addressed.
Why it matters: As lumbar spinal stenosis and related compressive radiculopathies remain common drivers of surgical spine care, CPT code 62331 captures a frequently used adjunctive procedure for multi‑level decompression. Proper coding affects facility and professional billing across hospital outpatient departments and ambulatory surgery centers and influences national utilization and payment patterns.
Key payers covered: Analysis commonly includes major national plans: Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare.
What readers will learn: This publication provides clinical context for the procedure represented by CPT code 62331, explains typical sites of service, and outlines what the code represents in practice. It also surveys payer coverage themes, typical reporting scenarios for additional lumbar interspaces, and related coding considerations. Where specific benchmark or policy data are required but not provided in the input, the text will state "Data not available in the input."
Billing Code Overview
CPT code 62331 describes a lumbar decompression procedure in which the provider partially removes the ligamentum flavum to relieve pressure on spinal nerves. The service includes creating an access opening in the lamina (laminotomy), performing epidurography, and using imaging guidance such as fluoroscopy or computed tomography.
Service Type: Surgical, spinal decompression (laminotomy with partial removal of ligamentum flavum), bilateral add-on
Typical Site of Service: Hospital outpatient department or ambulatory surgery center
Clinical & Coding Specifications
Clinical Context
A 62-year-old patient with chronic low back pain and unilateral lower-extremity radicular symptoms presents after failing conservative care including physical therapy, oral analgesics, and epidural steroid injections. Imaging (MRI lumbar spine) shows ligamentum flavum hypertrophy and lateral recess stenosis at L4-5 and L5-S1 with nerve root impingement. The patient is scheduled for a minimally invasive lumbar decompression procedure. Intraoperative workflow: preoperative verification and informed consent; general or monitored anesthesia care; fluoroscopic localization of target interspace(s); creation of a small laminotomy and partial removal of hypertrophied ligamentum flavum (decompression) at the first lumbar interspace; intraoperative epidurography to confirm epidural space and nerve root position; if additional adjacent lumbar interspace(s) require decompression, the bilateral add-on code is reported for each additional interspace after the first. Postoperative recovery involves routine PACU monitoring and discharge instructions with activity limitations and outpatient follow-up for wound check and neurologic assessment.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
50 | Bilateral procedure | When the decompression is performed on both sides and payer requires modifier instead of bilateral CPT reporting |
59 | Distinct procedural service | When a separate, distinct procedure (not bundled) is performed at a different spinal level or date that is unrelated to the primary service