Caralee Posted Wed 20th of June, 2012 18:43:03 PM
Patient had a previous kyphoplasty in which the cement had leaked into the epidural space, the surgeon had to go back to operating room to perform a laminectomy for decompression of the epidual space and then removal of the cement from T11 transpedicular approach. I need help w/ the ICD 9 code and CPT code(s). Thank you
SuperCoder Answered Thu 21st of June, 2012 08:04:17 AM
It seems that the current surgery was performed by using laminectomy technique. If that's the case, then code 63003 for "decompression of the epidual space". Removal of the cement from T11 transpedicular approach need not be coded separately.
SuperCoder Answered Thu 21st of June, 2012 09:05:58 AM
Since the visit is for repairing job and decopression, too, so code the Dx's as -->
996.49 (for failed joint fusion / leakage of cement)
For other Dx's, you need to look for the specific diagnosis mentioned and code accordingly. For example, spinal stenosis, nerve compression etc.