Neurosurgery Coding Alert

Question: When trying to accomplish an epidural anesthetic, the spinal needle broke off approximately 4-5 cm below the surface of the skin at the L2-L3 level. Our surgeon made a laminectomy incision for removal of retained spinal needle at L2-L3 level under continuous fluoroscopy. How can we report this?

New Mexico Subscriber

Answer: The scenario does not specify whether the epidural anesthetic was performed as anesthesia for another procedure or whether it was the intended procedure itself. If the latter, the physician performing the epidural anesthetic may report their service with the discontinued service modifier 53 (Discontinued procedure). The surgeon performing the laminectomy for removal of the foreign body would report unlisted code 64999 (Unlisted procedure, nervous system). While there are several CPT^® codes for removal of foreign bodies in various body areas (e.g. peritoneal cavity), there is no specific code for removal of a foreign body from the posterior spine. The CPT^® codes for excision by laminectomy for a lesion other than herniated disc are not intended to be used in this circumstance.