May 17, 2018

Question:
Our surgeon returned a patient to the OR for an I&D of a subfascial abscess after a spinal fusion from T2-S1; the abscess involved T10-L5. Our question is do we report CPT code 22010 and 22015?

Answer:
Thanks for your inquiry. The correct code is CPT code is CPT code 22015 (Incision and drainage, open, of deep abscess (subfascial), posterior spine lumbar, sacral, or lumbosacral) as the majority of the work is performed in the lumbar spine. Append modifier 78 if the patient is in a global period.

*This response is based on the best information available as of 05/17/18.