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Orthopedic Coding Alert

READER QUESTIONS :

Solve Second Surgery Coding

Published on Sat Jul 04, 2009

Question: One of our patients underwent a bilateral lumbar laminectomy, decompressive L3-L4 and L4-L5. Six days later, our orthopedist did an exploration of lumbar wound with evacuation of hematoma. The op note states that he evacuated the hematoma down to the thecal sac. He did a little bit of further facetectomy to make sure he could explore and probe the L5 nerve root on the left. There was some oozing, so he controlled this from the bone with bone wax. He used electrocautery on the muscular bleeders and placed a medium Hemovac deep and superficial. He loosely approximated the fascia with sutures. Also, he approximated the subcutaneous tissues with Monocryl. He closed the skin with 4-0 nylon sutures and activated the Hemovac. What should I code for the second surgery? New York Subscriber Answer: Because the hematoma involves a deep dissection, you should report 22899 (Unlisted procedure, spine). You can [...]
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