Neurosurgery Coding Alert

Question: One of our patients underwent a bilateral lumbar laminectomy, decompressive L3-L4 and L4-L5. Six days later, our neurosurgeon did an exploration of the lumbar wound with evacuation of the hematoma. The op note states that he evacuated the hematoma down to the thecal sac. He did a little bit of further facetectomy to make sure he could explore and probe the L5 nerve root on the left. There was some oozing, so he controlled this from the bone with bone wax. He used electrocautery on the muscular bleeders and placed a medium Hemovac deep and superficial. He loosely approximated the fascia with sutures. Also, he approximated the subcutaneous tissues with Monocryl. He closed the skin with 4-0 nylon sutures and activated the Hemovac. What should I code for the second surgery?

New York Subscriber

Answer: Because the hematoma involves a deep dissection, you should report 22899 (Unlisted procedure, spine). You can compare the work involved with 22015 (Incision and drainage, open, of deep abscess [subfascial], posterior spine; lumbar, sacral, or lumbosacral).

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) when your surgeon performs a procedure postoperatively during the global surgical period of the original procedure. This shows the carrier that this new procedure was related to the original surgical procedure.