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Removal of retained drain following craniotomy

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anicole76

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Dothan, AL
Our surgeon performed a craniotomy and the patient presented four days later with a retained drain. She was returned to the OR where it was discovered that the drain was trapped underneath one of the plates securing the skull flap back to the skull. An inicision and drainage with removal of retained drain was performed at that time. What would be the most accurate code to report this service? It has been suggested that an unlisted code be used, but we appreciate any feedback if someone knows a specific CPT code that would be appropriate. Thanks so much!
 
skull flap

I would suggest billing a cranioplasty code and use modifier 78 modifier.

Look at this CPT code

62143-78

Replacement of bone flap or prosthetic plate of skull
 
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