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CPT®
63615

CPT® Code 63615
Deleted

Official Description

Stereotactic biopsy, aspiration, or excision of lesion, spinal cord

© Copyright 2026 American Medical Association. All rights reserved.

Common Language Description

The CPT® Code 63615 refers to a stereotactic biopsy, aspiration, or excision of a lesion located in the spinal cord. This procedure is performed using advanced imaging techniques, such as CT (Computed Tomography) and MRI (Magnetic Resonance Imaging), which allow for precise localization of spinal cord abnormalities. Prior to the surgical intervention, these imaging studies are conducted to create a detailed three-dimensional representation of the spine, enabling the surgeon to identify the safest and most direct approach to the lesion. During the procedure, a small incision is made over the targeted area of the spine. Utilizing a surgical navigation system, the surgeon employs specialized instruments that are guided by the three-dimensional images to accurately navigate towards the lesion. The procedure may involve obtaining a tissue sample through biopsy forceps, collecting fluid or cellular samples via an aspiration device, or excising the lesion entirely with a surgical blade. The careful manipulation of instruments ensures minimal disruption to surrounding tissues. Once the procedure is completed, all surgical instruments are withdrawn, and the incision is closed, marking the end of the intervention.

© Copyright 2026 Coding Ahead. All rights reserved.

1. Indications

The procedure described by CPT® Code 63615 is indicated for the evaluation and management of lesions within the spinal cord. The specific indications for performing a stereotactic biopsy, aspiration, or excision include:

  • Spinal Cord Lesion - Presence of a lesion in the spinal cord that requires further investigation or treatment.
  • Diagnostic Purposes - Need for tissue sampling to determine the nature of the lesion, such as whether it is benign or malignant.
  • Symptomatic Lesions - Lesions causing neurological symptoms that may necessitate removal or aspiration to alleviate pressure or other complications.

2. Procedure

The procedure for CPT® Code 63615 involves several critical steps to ensure accurate targeting and intervention on the spinal cord lesion. The steps are as follows:

  • Step 1: Preoperative Imaging - Prior to the procedure, CT and MRI scans are performed to obtain detailed images of the spinal cord. These imaging studies are essential for identifying the location and characteristics of the lesion, allowing for the creation of a three-dimensional model of the spine.
  • Step 2: Surgical Planning - Based on the imaging results, the surgeon plans the approach to the lesion. This planning involves determining the safest and most direct route to access the lesion while minimizing potential damage to surrounding structures.
  • Step 3: Incision and Instrumentation - A small incision is made over the identified area of the spine. The surgeon then utilizes a surgical navigation system along with specialized instruments to guide the approach to the lesion accurately.
  • Step 4: Lesion Access - Using the three-dimensional imaging as a reference, the surgeon advances the appropriate instrument—either biopsy forceps, an aspiration device, or a surgical blade—toward the lesion. This step is performed with precision to ensure accurate targeting.
  • Step 5: Sample Collection or Excision - If a biopsy is indicated, the surgeon uses biopsy forceps to obtain a tissue sample from the lesion. If fluid or cellular samples are required, an aspiration device is employed. In cases where the lesion needs to be excised, the surgical blade is used to carefully remove the entire lesion.
  • Step 6: Closure - After the procedure is completed, all instruments are carefully withdrawn from the surgical site. The incision is then closed, ensuring proper healing and minimizing the risk of infection.

3. Post-Procedure

Following the completion of the procedure coded under CPT® 63615, post-procedure care is essential for patient recovery. Patients are typically monitored for any immediate complications, such as bleeding or infection at the incision site. Pain management may be provided as needed. The recovery period may vary depending on the extent of the procedure and the patient's overall health. Patients are usually advised on activity restrictions and follow-up appointments to discuss pathology results if a biopsy was performed. It is important for healthcare providers to provide clear instructions regarding wound care and signs of potential complications that should prompt immediate medical attention.
Short Descr REMOVE LESION OF SPINAL CORD
Medium Descr STRTCTC BX ASPIRAT/EXC LESION SPINAL CORD
Long Descr Stereotactic biopsy, aspiration, or excision of lesion, spinal cord
Status Code Active Code
Global Days 090 - Major Surgery
PC/TC Indicator (26, TC) 0 - Physician Service Code
Multiple Procedures (51) 2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 1 - Statutory payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Hospital Part B services paid through a comprehensive APC
Type of Service (TOS) 2 - Surgery
Berenson-Eggers TOS (BETOS) P1G - Major procedure - Other
MUE Not applicable/unspecified.
CCS Clinical Classification 9 - Other OR therapeutic nervous system procedures
Date
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Notes
2019-01-01 Deleted Code deleted
Pre-1990 Added Code added.
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