Neurosurgery Coding Alert

Question: In a patient who was diagnosed with a cervical epidural abscess in C6-T2, our surgeon did the following procedures:

• C6 and C7 hemilaminectomy
• Evacuation of cervical epidural abscess
• Use of intraoperative microscope

Can we report codes 63020 and 63035 for hemilaminectomy? Is there any additional code that we can report for the evacuation of the epidural abscess? Please suggest a diagnosis code for the cervical epidural abscess.

Ohio Subscriber

Answer: You report the evacuation of the cervical epidural abscess with code 63265 (Laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; cervical). For use of intraoperative microscope, you report +69990 (Microsurgical techniques, requiring use of operating microscope [List separately in addition to code for primary procedure]). The diagnosis code for spinal abscess is 324.1 (Intraspinal abscess).  If the laminectomy extended to T1, you would still report 63265 as the predominant location of the abscess.