Sharp and blunt dissection was utilized in both areas. Full hemostasis was obtained with Bovie cautery. Up opening of the incision , yellow discharge came out. Culture was taken from the top incision ( upper thoracic incision). The internal pulse generator and the extension wire were removed from the right side above the buttock area. The anchoring device was disconnected from the epidural lead. The epidural round lead was removed intact from the epidural space. Both incisions were checked for hemostasis repeatedly. Both incisions were irrigated with sterile normal saline mixed with bacitracin. Then JP drain was placed in each of the incision. The drains were secure with 2.0 Silk. The subcutaneous tissues were approximated using 2-0 Vicryl. The skin was approximated using staples. The incision was covered by gauze, telfa and tegaderm
My first thought is that this is included in the removal of the generator and leads. Then I started thinking
..this is outside of the original global period, there was more work performed that would have been performed just removing the system, we did place drains, etc. So, my questions are:
1. Would it be appropriate to bill for the incision and drainage in addition to the removal of the leads and generator?
2. If so, would we use 10060 (simple/single I&D) or 10180 (post-op wound infection) even though it is 6 weeks or so later?
3. Or would it be appropriate to add a -22 modifier to the lead extraction code as it appears that a lead incision was the infected site?
4. I am completely off base and should just bill 63661 and 63688
Thank you for your thoughts on this.