Wiki Evacuation of epidural hematoma, lumbar spine. Wound irrigation and debridement.


Humble, TX
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Not to long ago I started coding Neurosurgery. I was new to it, and I am still learning. I am getting the rejection for procedure below. Please help.

DIAGNOSIS: Epidural hematoma, lumbar spine.

1. Evacuation of epidural hematoma, lumbar spine.
2. Wound irrigation and debridement of superficial and deep wound, approximately 20 cm.

DESCRIPTION OF THE PROCEDURE: After induction of general endotracheal anesthesia, the patient was placed prone onto the operating table. All bony prominences were padded, and the skin was prepped and draped in the usual sterile fashion. A timeout was performed. The prior incision was reopened using Metzenbaum scissors followed by obtaining multiple cultures deep and superficial in nature. There is noted to be a significant amount of just liquefactive type of a drainage without any obvious purulent material. The superficial tissue and the fascia were opened up and interrogated. There was noted to be an epidural clot over the dura, which was removed using combination of brushings and currettes. Using the Aquamantys, bleeding, which was noted to be somewhat from around the tissues and the fascia, was controlled. At that point in time, a 3 L bacitracin soaked post-lavage was used to irrigate the would. Once the wound was completely irrigated, the borders of the skin were thereafter incised until clean margins. At that point, 2 medium Hemovacs were inserted and tunneled under a separate incision. The wound was thereafter closed in the usual fashion of 0 Vicryl for the fascia, which was very thin, friable and did not hold well. It was approximated to the best of my ability. The muscle, 3-0 Vicryl for the subcutaneous tissue and 3-0 nylon vertical locking matters for the skin. The patient tolerated the procedure well.

If anyone could please help me with this. What diagnosis and CPT code would you use?

I coded it as 11043 and 10140 with diagnosis code S34.109A, but Medicare Plus Blue is rejecting it.

The patient underwent an extensive lumbar operation, decompression and fusion by different provider 18 days prior to this procedure, and then presented to the emergency and my provider did the above procedure.

I would use CPT code 22015 for removal of deep abscess and dx code M96.830 Post procedural hematoma of the musculoskeletal structure following a procedure of the musculoskeletal system....

If you look under incision in the musculoskeletal part of the CPT code book 21501 says Incision and Drainage of deep abcess or hematoma soft tissue of neck/thorax but right underneath it in parenthesis it says see 22010-22015 for spine..hope this helps.