Neurosurgery Coding Alert

Question: A patient, who is a week status post-cervical laminectomy for the resection of the intramedullary ependymoma, has to have another surgery. The second surgery is an exploration of the cervical laminectomy and resection of the intradural hematoma and hematoma within the tumor cavity. The surgeon opened the fascia up, and there was hematoma under the fascia, which he removed. The surgeon then opened up the dura, and the blood clot was under pressure. The clot was over the spinal cord, which we removed. The patient also had a clot within the tumor cavity, which the surgeon irrigated and removed. Then, the surgeon sewed in a dural graft. Which CPT^® codes should we report for this?

Georgia Subscriber

Answer: The most definitive procedure among the subfascial hematoma, intradural hematoma, and intramedullary hematoma is the intramedullary hematoma. The other two hematoma removals were required to reach the intramedullary hematoma and are considered incidental. You would report the intradural and intramedullary hematoma excision with code 63270 (Laminectomy for excision of intraspinal lesion other than neoplasm, intradural; cervical). The additional dural graft placement may be separately reportable. Although primary dural closure is inclusive of the hematoma removal procedure, creation of an enlarged dural sac to accommodate postoperative cord swelling but sewing in a dural patch graft may be separately reported with code 63710 (Dural graft, spinal). Both of these codes should be appended with modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) to reflect the return to the operating room for treatment of a postoperative complication.