Neurosurgery Coding Alert

Question: The neurosurgeon performed lumbar decompression and fusion. Two weeks later he returned to surgery to explore the fusion, drain epidural abscess, debride the wound, and apply wound vacuum therapy. The diagnosis was epidural abscess. How should I code the second procedure? Oregon Subscriber Answer: Although your physician completed several procedures during the encounter, you'll report only 22015 (Incision and drainage, open, of deep abscess [subfascial], posterior spine; lumbar, sacral, or lumbosacral). Append modifier 78 (Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period) to indicate this encounter's connection with the original procedure. Diagnosis timing: Some coders might consider using diagnosis code 324.1 (Intraspinal abscess), but that's not the best choice in this situation. An abscess identified two weeks after surgery is considered a postoperative complication, so you should report 998.59 (Other postoperative infection).