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Wiki Exploration of laminectomy

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eguillot

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Hoping someone could help me figure out what CPT code to use for this! A patient is a week status post cervical laminectomy for resection of intramedullary ependymoma. The patient has to have another surgery. This surgery is an exploration of cervical laminectomy and resection of intradural hematoma and hematoma within the tumor cavity. The OP report states "We opened the fascia up and there was hematoma under the fascia that was removed. We then opened the dura and the blood clot was under pressure. Both the cuboid and clot was over the spinal cord. This was removed. There was also a clot within the tumor cavity which was irrigated and carefully removed. We then sewed in a dural graft." Thanks!
 
You should be coding this as just 10140 with modifier 79 for return to the OR. That is how we code all our post-op hematoma cases if not a laminectomy is not done again and its just explored.
 
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