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Spine Procedure Question

  1. #1
    Default Spine Procedure Question
    Medical Coding Books
    I need to know how to code a removal of a soft tissue mass or hematoma from the spine. My doctor did this procedure 2 weeks after the original laminectomy.

  2. Default
    Without knowing the details, cant really narrow it down. But I would look at codes 22015, 20005 or 10140. (10140 would be for something more superficial).

  3. #3
    The physician did a L5-S1 extension back in November. The patient started complaining of pain and after doing a CT scan the physician saw a soft tissue mass in the L5-S1 area. He took the patient back to the OR to remove this mass. He entered through the same incision from the previous surgery and "blood clot or organized hematoma was removed throughout the laminotomy site and around the L5-S1 area". After further exploration, the physician also removed "fibrous-like material which was intact with the dura". He wants to bill 63047 with modifier 52, but I'm wondering if there isn't a better code to describe what he did.

  4. Default
    I would show him 22015 and see if he thinks that would be more appropriate. 63047 doesnt really describe what he did.

  5. #5
    Greater Pittsburgh
    I agree with 22015 with a 78 modifier.
    jdemar, CPC, CMA

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