sumgall05
New
Hello! I am questioning the correct billing for a pt that presented with a lumbar spine wound infection s/p previous lumbar decompressive surgery. The provider wants to bill CPT 22015 (Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral) for the I&D (which is what I believe should be billed) and also 63042 for re-exploration. However, my interpretation of CPT 63042 is that some type of "revision" is also done, in addition to the exploration. Am I incorrect in my logic- can the provider bill that code just because he performed an exploration of the area? The majority of the note is in regards to the drainage and cleaning of the wound and only a brief mention of "visiting" the previous decompression site: "We did visit the wound at the base where the decompression was performed. It appeared to be somewhat irritated; however, we did not see the purulence, as we saw superficial to the fascia."