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Spinal fb removal

eortega

Guru
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124
Location
North Hollywood, CA
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Hi, I have a case for a spinal FB body (needle stuck) removal but I can't find a CPT code, I think I can use ASA code 00630 and the closest CPT I found is63267, do you know if this is OK?

Thanks & have a nice weekend!!
 

jdrueppel

Expert
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Lincoln, NE
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Erika,

I would be hesitant to use 63267 as CPT code states "lesion other than neoplasm". Did the surgeon do a laminectomy in order to remove the needle? There are alot of possibilities depending on the exact documentation. Can you post the Op Note?

Julie, CPC
 
Last edited:

eortega

Guru
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Location
North Hollywood, CA
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sure! as follows:
POSTOPERATIVE DIAGNOSIS: FOREIGN BODY CONSISTING OF A SEWING NEEDLE,
LUMBAR SPINE.

OPERATION:
1. REMOVAL OF FOREIGN BODY FROM DEEP SOFT TISSUES, LUMBAR SPINE.
2. INTRAOPERATIVE FLUOROSCOPIC IMAGING.

ANESTHESIA: General anesthesia.

PROCEDURE: The patient was identified in the holding area and brought to
the operating room and placed on the operating room table. General
anesthesia was induced by the anesthesia staff. The patient was placed
prone safely with proper padding. Lumbar area was prepped and draped.
Fluoroscopic imaging was then brought in and AP and lateral projections
were done to localize the foreign body. After this was accomplished, a
small incision was made in the midline back, correlating with the area of
the foreign body. Incision was carried down through skin and subcutaneous
tissues. Cautery was used to control bleeding. Minimal bleeding was
encountered. Dissection was conducted down to the level of the spinous
processes. In the right lateral aspect of the spinous processes,
intramuscular dissection was conducted until the needle was identified.
The needle was removed in its entirety and sent to pathology for
identification. At this point, copious lavage irrigation was done and the
wound was closed in layers. Sterile dressing was applied. The patient
was awakened successfully, placed on the stretcher and taken to the
post-anesthesia care unit in stable condition. There were no
complications throughout the case. The blood loss was minimal.
 

jdrueppel

Expert
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435
Location
Lincoln, NE
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Erika,

I don't have my CPT book with me but I think the CPT code for removal foreign body muscle deep is CPT code 20525 which I believe would cross to 00300. Take a look at these codes.

Julie, CPC
 
Last edited:

eortega

Guru
Messages
124
Location
North Hollywood, CA
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I see what you're saying Julie, I should assign the correspondent cpt depending on the location (extent) of the FB, not the area (as I thought).

Thanks and happy monday!!
 
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