My physician did a kyphoplasty on 08/25/17. On 08/30/17, she returned to the office complaining of increased left sided back pain. An x-ray revealed cement casting. On 09/06/17, she returned to the OR to have the cement casting removed. Below is part of the report:
After identifying the left T11 Kyphoplasty cement cast fluoroscopically, the skin was sterilely prepped and draped in the usual fashion using betadine times three. The skin and subcutaneous tissues were anesthetized with 1% Lidocaine using a 25 gauge 1.5 inch needle and a 25 gauge 3.5 inch spinal needle for deeper tissues. Then the 25 gauge 3.5 inch spinal needle was used to inject 0.5% bupivicaine with epinephrine for further local anesthetic control and hemostasis. An 11-blade scalpel was used to make a 1-2 cm incision overlying the left T11 Kyphoplasty cement cast. Soft tissue dissection was then carried out along the left T11 Kyphoplasty cement cast down to where the cast enters the left T11 pedicle. A needle driver was then used to grasp the cement cast at the junction where the cast enters the left T11 pedicle. The cast was then severed from the left T11 pedicle juncture and removed from the body without difficulty. The incision site was then copiously irrigated with saline mixed with bacitracin. The deep soft tissues were closed using 2.0 vicryl sutures. The skin was closed using a skin stapler.
How do I bill for this? I looked at the "foreign body removal" codes, but none of those fit. Any assistance will be greatly appreciated.