Patient had undergone redo lumbar discectomy a week and a half prior where a ventral dural tear was found from the disc herniation. This was patched with Gelfoam and Tisseel. Patient presented with recurrent radicular pain and weakness, for which this surgery was scheduled under the assumption there was a postop fluid collection or possible re-herniation of disc.
From op note:
PROCEDURES: "Incision and drainage and re-exploration of right L4-L5 wound."
INDICATIONS: "...It was found the nerve root was compressed due to the Gelfoam and Tisseel."
PROCEDURE IN DETAIL:
"... Gradually Tisseel and Gelfoam were dissected off the dura, and the L5 nerve root was eventually identified, and a wide foraminotomy of L5 was then performed. The ventral epidural space was explored, and a small amount of Gelfoam removed from it, and what may have been a small recurrent fragment of disk as well. The bony edges were explored above and below the exposure, and no further compression was identified. After this, fortunately, there was no CSF found to be leaking, and there was no obvious neural compression." Op note goes on to indicate operating microscope was used and details the irrigation and closure of wound.
My question is what CPT code to use for this procedure? It doesn't sound like he was certain of a re-herniation of disc. I don't know if the Gelfoam and Tisseel would be considered a surgical foreign body left behind nor hardware removal. We're considering I&D procedures, but no infection found and what about the foraminotomy done at L5 for nerve compression? Wouldn't this be above and beyond an I&D procedure?
If anyone has any experience with this kind of scenario or ideas on how to code, assistance would be appreciated.
From op note:
PROCEDURES: "Incision and drainage and re-exploration of right L4-L5 wound."
INDICATIONS: "...It was found the nerve root was compressed due to the Gelfoam and Tisseel."
PROCEDURE IN DETAIL:
"... Gradually Tisseel and Gelfoam were dissected off the dura, and the L5 nerve root was eventually identified, and a wide foraminotomy of L5 was then performed. The ventral epidural space was explored, and a small amount of Gelfoam removed from it, and what may have been a small recurrent fragment of disk as well. The bony edges were explored above and below the exposure, and no further compression was identified. After this, fortunately, there was no CSF found to be leaking, and there was no obvious neural compression." Op note goes on to indicate operating microscope was used and details the irrigation and closure of wound.
My question is what CPT code to use for this procedure? It doesn't sound like he was certain of a re-herniation of disc. I don't know if the Gelfoam and Tisseel would be considered a surgical foreign body left behind nor hardware removal. We're considering I&D procedures, but no infection found and what about the foraminotomy done at L5 for nerve compression? Wouldn't this be above and beyond an I&D procedure?
If anyone has any experience with this kind of scenario or ideas on how to code, assistance would be appreciated.