Please help w/spine coding

Lisa Heikes

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I'm looking for a code for exploration of previous laminectomy site and search for possible CSF leak. My physician does not do the best op note. But here is goes.

OP note...The previous incision was opened and the paravertabal muscles were incised I entered a sizable cyst. This was filled with xanthochromic fluid. The cyst did not communicate with the subarachnoid space. We had the patient Valsalva several times by Anesthesia and there was no increased leakage or anything. It was my impression that this was a postoperative resolving hematoma. The cyst wall was obliterated. The epidural space was explored from L3 to the sacrum. The nerve roots were nicely intact. There were no neural elements present outside the dural sac as well. Following this Gelfoam was placed over the dura. The muscle was closed with Vicryl, ....

THANKS:
:confused:
 

RebeccaWoodward*

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What about 63042...reexploration?

Excerpt from CPT Assistant...

"The term ‘reexploration' simply relates to the repeat surgical exposure of a previous surgical tract and target at the same site on the same patient at a time after an initial surgical procedure(s) was performed."
 

nreading

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exploration spine

The closest you will get is 22830, your question did not indicate there was a fusion, so you may need to go unlisted and use this as a price point. Your note did not indicate any bony work, as such the 63042 would not be appropriate. The 63042 adds re-exploration to the laminectomy etc. to add weight for a difficult dissection in addition to the listed surgical procedures.

Hope this helps

Nancy Reading RN, BS, CPC
 

RebeccaWoodward*

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I don't disagree that 63042 was a stretch. I agree that 22830 would not be appropriate since, as you mentioned, there isn't any mention of a fusion.

Is this the entire report?
 
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