Question Therapeutic Wound Exploration and lysis of lumbar adhesions.

vmejias43

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Our pain management doctor performed a procedure which was authorized under CPT code 11043 - Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less.

This is what the doctor documented:
The patient was brought back into the operating room, given 2 g of Ancef IV prior to the procedure start. The midline incision where he had multiple surgeries was incised about 4 cm in length vertically. Using blunt dissection and electrocautery, we dissected down to the supraspinatus ligament and found multiple adhesions which had developed into a tiny ball which has been causing his pain whenever he would sit, stand, wa1k and sit in a chair. Using blunt dissection and electrocautery, we dissected out the scar tissue and removed it ensuring that the spinal cord stimulator leads did not leave their position in the epidural space. Electrocautery was used again for bleeding and hemostasis. Following incision and lysis of adhesion, we closed the subcu with 2-0 Vicryl in interrupted fashion and then skin with 3-0 nylon in interrupted fashion. Telfa Tag dressing and a pressure dressing on top of that to ensure no more bleeding.
The patient did great. Vitals were stable, before, during, and after. He was brought to the recovery room in stable condition and discharged to home in stable condition.

Do you think that we can bill this as 20251 - Biopsy, vertebral body, open; lumbar or cervical.
The guidelines state: Excision of subcutaneous soft connective tissue tumors (including simple or intermediate repair) involves the simple or marginal resection of tumors confined to subcutaneous tissue below the skin but above the deep fascia. These tumors are usually benign and are resected without removing a significant amount of surrounding normal tissue. Code selection is based on the location and size of the tumor. Code selection is determined by measuring the greatest diameter of the tumor plus that margin required for complete excision of the tumor. The margins refer to the most narrow margin required to adequately excise the tumor, based on the physician's judgment. The measurement of the tumor plus margin is made at the time of the excision. Appreciable vessel exploration and/or neuroplasty should be reported separately. Extensive undermining or other techniques to close a defect created by skin excision may require a complex repair which should be reported separately. Dissection or elevation of tissue planes to permit resection of the tumor is included in the excision. For excision of benign lesions of cutaneous origin (eg, sebaceous cyst), see 11400-11446.

This is what is leading me more towards 20251.

What do you think?​

 
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