Wiki ICD 10 code-We are tyring to

[sdunaway1]

We are tyring to code out a charge for a revisit to the operating room for a misplaced LC7 lateral mass screw and need some guidance of which ICD 10 code would be most appropriate. The patient originally had a fusion and decompression w instrumentation of C7-T1, T1-T2 due to a trauma. Durring the operation , they were not able ot do any fluorsoscoy because of the patient's large and wide shoulders and so localization and guidance of placement of instrumentation was not possible. The post op CT scan showed the L C7 lataeral mass screw partially within the lateral gutter posterior to the LC7 vertebral body. Based on this finding on the CT scan, the pt was taken back to redirect the LC7 lateral mass screw.

We have coded this charge as:

22849-78
22830-78-51-59
22852-78-51-59

T84.226

Can you please give me your oppinion?

Thank you!

 

[CodingKing]

22830 cannot be billed separately. Its bundled per NCCI

Exploration of the surgical field is a standard surgical practice. Physicians should not report a HCPCS/CPT code describing exploration of a surgical field with another HCPCS/CPT code describing a procedure in that surgical field. For example, CPT code 22830 describes exploration of a spinal fusion. CPT code 22830 should not be reported with another procedure of the spine in the same anatomic area. However, if the spinal fusion exploration is performed in a different anatomic area than another spinal procedure, CPT code 22830 may be reported separately with modifier 59.

Per CPT manual, Reinsertion includes the removal. You cannot report 22849 with 22850, 22852, and 22855 at the same spinal levels.

All you are left with is 22849-78