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Evacuation of fluid collection (abscess)

Cari Posted Thu 23rd of February, 2012 18:26:05 PM

Patient having an L4-S1 laminectomy for evacuation of fluid collection.

Would code 63172 be appropriate? Is that only for 1 segment?

What if foraminotomy done too, then 63047 with 63048 x 2

SuperCoder Answered Fri 24th of February, 2012 08:41:42 AM

CPT code 63172 is for drainage of intramedullary cyst (subarchanoidal space) and the approach to perform 63172 must be lateral extracavitary approach.
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For the spinal cyst at level L4-L5 and L5-S1 the correct code would depend on the location of the cyst. If it was extradural (outside the dura mater) then the code is 63267 (laminectomy for excision or evacuation of intraspinal lesion other than neoplasm, extradural; lumbar) with modifier -22 (unusual procedural services) to reflect the second level. If the cyst was intradural (enclosed in the dura), the code would be 63272 (laminectomy for excision of intraspinal lesion other than neoplasm, intradural; lumbar).
In addition, the codes for removal of an intraspinal lesion include the laminectomy, and the coder cannot code for additional levels involved in the lesion removal.
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It’s ok to report CPT code 63047 and 63048 for foraminotomy.
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It is suggested to check CCI bundling before reporting.
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