Wiki CPT help-Evacuation of a hematoma

[kdsampson]

I'm not sure what to use for this procedure:

Patient underwent L3-4 posterior fusion two weeks ago and presented with a large compressive epidural hematoma at the L3-4 level.

I made an incision over the old incision line and removed all of the sutures as I dissected my way down through the fascia. I was then immediately able to identify a very large hematoma; this was under much pressure under the fascia and was causing significant thecal sac compression. I was able to remove the hematoma in a piece meal fashion. I thoroughly irrigated the wound. When I was happy with the decompression and the removal of the hematoma I maintained hemostasis; I used bipolar and FloSeal to do this. When I was finished there was no further bleeding or neural compression. I did opt to place a drain; I sewed the drain into place and closed the wound in my usual layered fashion...

I've heard Margie Vaught with Decision Health's presentation and 22015 is for abscesses only per that. 10140 is too superficial for this. Do I use 11043 or unlisted?

Any help is greatly appreciated.

 

[thomas7331]

11043 is mainly used for wound care and I don't think it fits this situation well. It's a little hard to tell from the report where the physician is working anatomically but if this is an epidural hematoma, then 11043 is not really accurate and would also substantially under-reimburse the physician for this. Ortho is not my specialty, but I'm inclined to think that 22830 is closer to what is happening here since it's a re-exploration of the original surgery site. Otherwise an unlisted code with either 22015 or 22830 as a comparative code for expected reimbursement. But I'd defer to someone with more experience in this specialty for a definitive answer.

 

[kdsampson]

Thank you. I didn't feel very confident with the 11043 either, but I just thought that surely there would be a code for this. It looks like, unless someone else has advice on this that it will be unlisted.

Thank you!