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Aspiration of Spinal Cyst

Nicole Posted Wed 06th of August, 2014 10:07:16 AM

The doctor was going to do an Epidural Steroid Injection (Lumbar) on a patient. When they stuck the needle in, a pus like substance came out. So instead the doctor ended up doing an "Aspiration of Spinal Cyst".

This aspiration was before the spinal canal and the epidural space was not reached.

Would this be CPT code 62268? My concern with this code, is the cyst was not adhered to the spinal cord.

SuperCoder Answered Thu 07th of August, 2014 02:34:52 AM

Thanks for your question.

Did he also performed the Epidural steroid injection in the same session. If yes, then cyst aspiration will be considered as inclusive to injection.

Otherwise, you may use code 10060.

10060 represents 'Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single.'

Thanks !!

Nicole Posted Thu 07th of August, 2014 11:33:58 AM

No, the Epidural Injection was not done as planned. It was just the "Aspiration of Spinal Cyst" that was performed.

Just for clarification, if the cyst was on the spinal cord, then it would be the 62268. Since it is not, it is just the I & D code 10060.

What would make this complicated in order to bill the 10061?

Thank You For The Help!

SuperCoder Answered Fri 08th of August, 2014 16:37:49 PM

There are combination of factors that warrants the use of code 10061.

The most important being the insertion of a drain or gauze that would require a follow-up visit within the ten day post-op period. Obviously, the insertion of a drain or gauze would indicate that the treatment of the lesion is not simple, but requires more effort, skill, and supplies. Additionally, the need for another visit within the global period is also required for drain removal and wound care assessment.

Other criteria could include infection, the size of the lesion, the need for culturing and, complexity of the dressing. The combination of any of these may substantiate the use of the more complicated code although there is nothing formally written on this subject.

Hope it helps. Thanks !!

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