Orthopedic Coding Alert

Question: Which codes should we report for an incision and drainage of a lumbar wound that occurred following a patient’s fusion? The infection was both deep and superficial.

Kentucky Subscriber

Answer: You should report 22015-78 (Incision and drainage, open, of deep abscess [subfascial], posterior spine; lumbar, sacral, or lumbosacral; Return to the operating room for a related procedure during the postoperative period) if the surgeon took the patient back to the operating room for the incision and drainage during the global period.

You should report just one unit of 22015, despite the fact that the surgeon noted that the wound was both deep and superficial. In most instances, the physician performs both the deep and superficial I&Ds through the same incision and during the same session.

Remember: All debridement and I&D procedures that include the word “deep” in their descriptions would include the surgeon’s work addressing superficial layers. The Correct Coding Initiative (CCI) states: “If two procedures only differ in that one is described as a ‘superficial’ procedure and the other as a ‘deep’ procedure, the ‘superficial’ procedure is included in the ‘deep’ procedure and is not separately reportable unless the two procedures are performed at separate patient encounters or at separate anatomic sites.