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Wiki Epidural hematoma

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deickbush

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I am looking for a CPT code for drainage of an epidural hematoma.

The patient had fusion two weeks prior.

“Previous incision was opened…incision down to dura… Instrumentation explored, found to be solid… Blood and tissue overlying the dura was carefully removed and the dura completely decompressed”

There was no infection present, so I'm at a loss as to what code to use. Thanks!
 
exploration of fusion

How about 22830 (exploration of spinal fusion), since that is documented. Add modifier 78 if the same surgeon did both procedures.

You are right, can't use 2201X series because of no infection or abscess.
 
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