Neurosurgery Coding Alert

Question: Our surgeon opened a cystic wall to drain a fluid collection in the lumbar spine. On opening the subcutaneous tissue, there was a large amount of fluid collection which was opened following which the wall of the cavity was removed using monopolar cautery. The cystic collection was infiltrating under the fascia which was followed and removed completely along all the walls of the collection. Are we correct to report 22015 (Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral)? Is code 10140 (Incision and drainage of hematoma, seroma or fluid collection) a better choice?

New Mexico Subscriber

Answer: The question is not clear regarding whether the "cyst" is in fact a seroma compared with an infected abscess. You should report just one unit of 22015 if the fluid collection is an abscess with subfascial extension, despite the fact that the surgeon noted that the wound was both deep and superficial. In most instances, the surgeon performs both the deep and superficial I&Ds through the same incision and during the same session. Also remember - all debridement and I&D procedures that include the word ‘deep’ in their descriptions would include the surgeon’s work addressing superficial layers. If the collection represented a seroma collection, than one would report 10140. You may need to report modifier 78 (Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period) if this patient underwent surgery and remain in the global period of that procedure.