Neurosurgery Coding Alert

Question: According to the OP note, the surgeon prepped and anesthetized the patient, then he made an incision in the patient’s skin over a deep abscess on the patient’s lumbar spine. The surgeon then dissected down through the soft tissue and superficial fascia to the deep fascia adjoining the muscle layer. He debrided the tissue to remove necrotic tissue and purulent pus. Then, the surgeon irrigated the area and inserted a drainage tube. He checked for bleeding and closed the incision. We have no idea what CPT^® code to report for this procedure. Could you please help?

California Subscriber

Answer: Assuming the abscess was below the deep fascia, you would report 22015 (Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral) for this procedure.

Don’t miss: In this example, the surgeon removed an abscess from the patient’s lumbar spine. This code also applies to the incision and drainage of a deep abscess of the sacral or lumbrosacral spine. If, instead the surgeon performs this procedure on the patient’s cervical, thoracic, or cervicothoracic spinal region, then you would report 22010 (Incision and drainage, open, of deep abscess, (subfascial), posterior spine; cervical, thoracic, or cervicothoracic), instead.

Caution: You should never report 22015 in conjunction with 22010 (Incision and drainage, open, of deep abscess (subfascial), posterior spine; cervical, thoracic, or cervicothoracic), according to CPT^®. You should also never report 22015 in conjunction with incision and drainage of a postoperative wound or instrumentation removal codes 10180 (Incision and drainage, complex, postoperative wound infection); 22850 (Removal of posterior nonsegmental instrumentation (eg, Harrington rod)); or 22852 (Removal of posterior segmental instrumentation). If the infection was above the fascia, you would report code 10180 rather than 22015.