Neurosurgery Coding Alert

Question: The surgeon completed re-exploration, debridement of infected lumbar wound and L2-L3 disc space, and drain placement. He opened the old incision, exposed the spinous process, removed the spinous process, and thinned the lamina. He dissected the entire extent of the thecal sac while looking for locuated abscess collection. He removed additional bone to aid dissection and further free the thecal sac. Findings included a thick fibrous mass over the surrounding thecal sac. How do I code this?

North Carolina Subscriber

Answer: Several options for wound exploration, debridement, and lamina removal might come to mind, depending on the reason for the re-exploration.

• If the patient developed an infection related to the prior surgery, the appropriate code is 22015 (Incision and drainage, open, of deep abscess [subfascial], posterior spine; lumbar, sacral, or lumbosacral). If the re-exploration occurred within 90 days of the original procedure, append modifier 78 (Unplanned return to the operating/ procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to 22015.

• If the patient developed discitis and osteomyelitis spontaneously in the L2-L3 disc space after prior surgery in the distant past, a correct choice includes 63042 (Laminotomy [hemilaminectomy], with decompression of nerve root[s], including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc, reexploration, single interspace; lumbar).

• Since the surgeon performed additional bony work and decompressed the thecal sac with drainage of a spinal abscess, you might also consider 63267 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar).

Bilateral catch: If your surgeon completes the procedure bilaterally, append modifier 50 (Bilateral procedure) to your claim if code 63042 best reflects the work performed.