Nicole Posted Wed 13th of June, 2018 09:25:55 AM
Patient was shot in the right side of his body. CT scan revealed evidence of intrathecal bullet as well as bony fragment. Patient had a decompressive bilateral total laminectomy at T12-L1. The ligamentum flavum was removed and immediately upon doing so, the dura had three significant lacerations. The Cauda equina was delicately explored. Within the spinal canal was a large bullet. This was retrieved and delivered. Exploring further it appeared the bullet trajected into the canal, it injured the right facet joint and the cartilaginous facet joint was in the spinal canal. This was removed from the canal. Then the three lacerations were individually closed. Would the following codes be correct- Decompressive laminectomy T12-L1 w/ exploration and/or decompression of spinal cord and/or cauda equine (63003), Exploration penetrating wound (20102), removal of bullet in spinal canal and intrathecal bone fragment (20525). Not sure if anything can be billed for the repair of three lacerations to the dura (63709?)
SuperCoder Answered Thu 14th of June, 2018 05:28:08 AM
All three codes mentioned above are correct except for 63709. If a dural (cerebrospinal fluid) leak occurs during a spinal procedure, repair of the dural leak is integral to the spinal procedure. CPT code 63707 or 63709 (repair of dural/cerebrospinal fluid leak) should not be reported separately for the repair. Please feel free to ask for any further query.
Nicole Posted Thu 14th of June, 2018 08:00:32 AM
During the exploration it was noticed that the dura had three lacerations from the bullet and all three laceration were repaired. Would this still be considered inclusive to the spinal procedure 63003?
SuperCoder Answered Wed 20th of June, 2018 10:10:44 AM
Even if there is repair of laceration, we will not bill CPT 63709 but go for unlisted code (64999). CPT code 63707 or 63709 are for repair of dural/cerebrospinal fluid leak. In above mentioned report there is no mention of CSF leakage. Also you should include a cover letter stating why you are using the unlisted procedure code. This separate report should explain, in simple, straightforward language, exactly what the physician did. Hope it helps.