During the exposure of a thoracic lami for excision of abscess my surgeon encountered a paraspinal abscess. I have 3 coding options. Which would you use?
1. Code the lami (63266) and 20005 (Incision of soft tissue abscess, deep or complicated)
2. Code the lami and 22010 (Incision and drainage, open, of deep abscess (subfascial), posterior spine, cervial, thoracic or cervicothroacic)
3. Consider it part of the lami.
From the op note:
...to expose the thoracic spine including spinous process and lamina of T2, T3 and T4 and exposing the thoracic spine, a paraspinal abscess was entered and a large amount of purulent material was identified, sent for culture and irrigated clean. Once the paraspinal abscess had been debrided and irrigated, a Leksell rongeur and 2&3 Kerrison punches were used to complete the laminectomy at T2, T3 and medial facetectomy. There was a large epidural abscess, which was entered and removed using microsurgical techniques and stripped off the dura......
Oh would you code the operating microscope?
Thanks!
Anna
1. Code the lami (63266) and 20005 (Incision of soft tissue abscess, deep or complicated)
2. Code the lami and 22010 (Incision and drainage, open, of deep abscess (subfascial), posterior spine, cervial, thoracic or cervicothroacic)
3. Consider it part of the lami.
From the op note:
...to expose the thoracic spine including spinous process and lamina of T2, T3 and T4 and exposing the thoracic spine, a paraspinal abscess was entered and a large amount of purulent material was identified, sent for culture and irrigated clean. Once the paraspinal abscess had been debrided and irrigated, a Leksell rongeur and 2&3 Kerrison punches were used to complete the laminectomy at T2, T3 and medial facetectomy. There was a large epidural abscess, which was entered and removed using microsurgical techniques and stripped off the dura......
Oh would you code the operating microscope?
Thanks!
Anna
