Neurosurgery Coding Alert

Question: The patient who underwent a lumbar laminectomy on 14 Nov 2012, developed headache and significant neck pain in the subsequent weeks. CT scans were done and the patient was found to have an epidural hematoma at C4 which was treated on 4 Dec 2012. How do we report this service? Please also help on the diagnosis codes for the epidural hematoma.

New Jersey Subscriber

Answer: For the initial lumbar laminectomy, you may report code 63005 (Laminectomy with exploration and/or decompression of spinal cord and/or cauda equina, without facetectomy, foraminotomy or discectomy [e.g., spinal stenosis], 1 or 2 vertebral segments; lumbar, except for spondylolisthesis) or 63047 (Laminectomy, facetectomy and foraminotomy [unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis)], single vertebral segment; lumbar), depending upon whether medial facetectomy is additionally performed.

You might report ICD-9 code 998.12 (Hematoma complicating a procedure) for the hematoma as this developed following a lumbar laminectomy, but only if you can determine that the cervical hematoma is a complication of the lumbar surgery. You would report 63265 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical) for the cervical laminectomy to excise the C4 extradural hematoma. This should be appended with the 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) modifier if it is determined that the hematoma is a consequence of something other than the lumbar laminectomy surgery (e.g., anticoagulation that was resumed to treat atrial fibrillation).