Neurosurgery Coding Alert

Question: Encounter notes indicate that during an office evaluation and management (E/M) service for a new patient, the surgeon ordered an ultrasound (US) of the spinal canal, which was performed by a radiologist. Upon viewing the US, the surgeon diagnosed cervicothoracic osteomyelitis; the next day, they performed open incision and drainage (I&D) of the cervicothoracic spine. Notes indicate the surgeon performed moderate-level medical decision making (MDM) during the E/M. How should I report this encounter?

AAPC Forum Subscriber

Answer: Based on your question, the I&D was likely performed for a paraspinal abscess diagnosed during the US. On the claim, you should report:

• 22010 (Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic) for the I&D
• 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.) for the E/M
• Modifier 57 (Decision for surgery) appended to 99204 to show that the E/M was a separate and significantly identifiable service
• M46.23 (Osteomyelitis of vertebra, cervicothoracic region) appended to 22010 and 99204 to represent the patient’s osteomyelitis.