Neurosurgery Coding Alert

Question: How should I report incision and drainage of a postoperative wound due to infection following a laminectomy? I-m leaning toward 10180.

Nebraska Subscriber

Answer: Until 2006, 10180 (Incision and drainage, complex, postoperative wound infection) was probably your best choice for this type of incision and drainage (I&D). Since that time, however, CPT has given you two potentially better options: 22010 (Incision and drainage, open, of deep abscess [subfascial], posterior spine; cervical, thoracic, or cervicothoracic) and 22015 (... lumbar, sacral, or lumbosacral). You should apply these codes as appropriate to the general area (upper back or lower back) that the surgeon treats.

Remember to 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 either 22010 or 22015 when your neurosurgeon performs the I&D postoperatively during the global surgical period of the original procedure. This shows the carrier that the I&D procedure was related to the original surgical procedure.

Dx tip: To provide medical necessity for your claim, be sure that you assign an appropriate ICD-9 code for the postoperative wound infection, as well.