Wiki Incision and Drainage coding help needed

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cortinaz

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Can someone please give me advise on how to code the following:


Following the smooth induction of general endotracheal anesthesia, the patient was positioned prone on the Wilson frame. Lumbar region was prepped and draped in the usual sterile fashion. An 18 mm skin incision was reopened and a series of dilator tubes were docked over the L5-S1 interspace. This was confirmed via fluoroscopy. The prior laminotomy was identified. There was healthy healing granulation tissue. This was dissected free such that I could gain entry to the disk space. Numerous cultures were then sent for aerobic, anaerobic, AFB and fungal. I also entered the disk space and removed a small amount of disk material and sent that for culture as well, Next, 1 L of bacitracin irrigation was then utilized and Marcaine was placed over the nerve root. The wound was then closed with 3-0 Vicryl, 4-0 Vicryl, and Steri Strips. All sponge and needle counts were reported to be correct by the nursing staff upon completion of procedure.

Any help is appreciated. Thank you in advance.
 
Hi!

I am fairly new to spine coding, but I think this would more than likely fall into the category of CPT 22015. Hope this can give you a little insight or guidance in the right direction. Let me know if you come up with something different.
 
Thanks Jennifer. I looked at that one too. My only concern is that there is no mention in the report of abscess or an infection mentioned so I'm hesitant to use that one.
 
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