I need help with coding this case:
Open placement of subarachnoid shunt for external decompressive drainage
Details:
patient undergoing corrective lumbar spine surgery resulting in dural tear so a subarachnoid drainage shunt was requested by surgeon.
Patient was still under general anesthesia and still with sterile skin prep from the prior surgery, using an OEC 9800 fluoroscopic monitor, a 17-guage Tuohy needle passed through the skin at approximately 30 degrees at the level of the skin and directed into the right side of the posterior L5 vertebral space. The ligamentum flavum was identified. The epidural space was identified with a loss of resistance and a saline-filled plastic syringe. The stylet was then replaced and the needle was then passed further into the subarachnoid space. There was bloody-tinged cerebral spinal fluid flowing easily. A 19-guage epidural tray (Smiths) passed easily without obstruction into the subarachnoid space, approximately 6cm. The Tuohy needle and stylet were then removed and the injection hub was then screwed on to the end of the catheter. there was clear unfettered flow of bloody-tinged cerebral spinal fluid. The drainage catheter was then dried, the area prepped with Mastisol. The catheter was then secured to the skin with 1-inch Steri-Strips. the injection port was then secure to the tube with 1-inch Steri-Strips. A PCA extension tubing was then placed at the port and connected to a biliary drainage bag in a sterile manner. The connectors were all secure with a 1-inch Steri-Strips. There was a smooth flow of the cerebral spine fluid. The bag was marked as CSF drainage.
Dx Code: 997.09
CPT: 63740 v 63741
This was open placement but no laminectomy was done...would 63740 still be appropriate?
Open placement of subarachnoid shunt for external decompressive drainage
Details:
patient undergoing corrective lumbar spine surgery resulting in dural tear so a subarachnoid drainage shunt was requested by surgeon.
Patient was still under general anesthesia and still with sterile skin prep from the prior surgery, using an OEC 9800 fluoroscopic monitor, a 17-guage Tuohy needle passed through the skin at approximately 30 degrees at the level of the skin and directed into the right side of the posterior L5 vertebral space. The ligamentum flavum was identified. The epidural space was identified with a loss of resistance and a saline-filled plastic syringe. The stylet was then replaced and the needle was then passed further into the subarachnoid space. There was bloody-tinged cerebral spinal fluid flowing easily. A 19-guage epidural tray (Smiths) passed easily without obstruction into the subarachnoid space, approximately 6cm. The Tuohy needle and stylet were then removed and the injection hub was then screwed on to the end of the catheter. there was clear unfettered flow of bloody-tinged cerebral spinal fluid. The drainage catheter was then dried, the area prepped with Mastisol. The catheter was then secured to the skin with 1-inch Steri-Strips. the injection port was then secure to the tube with 1-inch Steri-Strips. A PCA extension tubing was then placed at the port and connected to a biliary drainage bag in a sterile manner. The connectors were all secure with a 1-inch Steri-Strips. There was a smooth flow of the cerebral spine fluid. The bag was marked as CSF drainage.
Dx Code: 997.09
CPT: 63740 v 63741
This was open placement but no laminectomy was done...would 63740 still be appropriate?