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Spinal fb removal

  1. Question Spinal fb removal
    Medical Coding Books
    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!!

  2. #2

    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 by jdrueppel; 10-04-2009 at 08:35 AM. Reason: spelling correction

  3. Default
    sure! as follows:


    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.

  4. #4

    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 by jdrueppel; 10-04-2009 at 08:37 AM.

  5. Default
    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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