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Removal of Cystic wall and fluid collection in the lumbar spine

Caralee Posted Fri 16th of November, 2012 16:59:40 PM

The subcutaneous tissue was opened and there was a large amount of fluid collection. Opened the fluid collection and then started removing the wall of the cavity w/ the monopolar cautery. The cystic collection was infiltrating under the fascia which was followed and removed completely all the walls of the collection. The I&D code I believe to be 10140 but not sure if it is 22015 and what code for the cystic wall removal.

SuperCoder Answered Mon 19th of November, 2012 04:58:48 AM

You should report just one unit of 22015, despite the fact that the surgeon noted that the wound was both deep and superficial. In most instances, the physician performs both the deep and superficial I&Ds through the same incision and during the same session.

Remember: All debridement and I&D procedures that include the word -deep- in their descriptions would include the surgeon's work addressing superficial layers.

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