Neurosurgery Coding Alert

Question: How can we report for excision of previous scar with skin margins and re-exploration of Rt. L4-5 laminectomy defect?  Our surgeon found a seroma and drained it.

New York Subscriber

Answer: Assuming that a post-operative wound infection was identified since exposure was below the fascia down to the laminectomy defect, this is best reported with 22015 (Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral). The scar excision would be considered incidental and not separately reportable.