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The procedure described by CPT® Code 22015 involves the incision and drainage of a deep abscess located in the posterior spine, specifically in the lumbar, sacral, or lumbosacral regions. An abscess is a localized collection of pus that can occur due to infection, and in this case, it is situated beneath the fascia, which is a layer of connective tissue that surrounds muscles and organs. The process begins with making an incision in the skin over the site of the abscess, allowing access to the underlying tissues. The incision is extended through the soft tissue and fascia to reach the abscess pocket. Once accessed, the abscess is opened, and any loculations—small compartments within the abscess—are disrupted using blunt finger dissection. This technique helps to ensure that the entire cavity is adequately drained. Following this, the abscess cavity is typically irrigated with saline or an antibiotic solution to cleanse the area and reduce the risk of further infection. Depending on the size and nature of the abscess, drains may be placed to facilitate ongoing drainage. After the procedure, the incision may be closed in layers to promote healing or packed with gauze and left open to allow for continued drainage and monitoring. It is important to differentiate this procedure from similar ones performed in other spinal regions, such as the cervical or thoracic spine, which are coded differently (CPT® Code 22010).
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The procedure described by CPT® Code 22015 is indicated for the management of deep abscesses located in the posterior spine, specifically in the lumbar, sacral, or lumbosacral regions. These abscesses may arise due to various underlying conditions, including infections that can lead to the accumulation of pus beneath the fascia. Symptoms that may prompt this procedure include localized pain, swelling, redness, and fever, which are indicative of an infectious process. The presence of a palpable mass or fluctuance in the area may also suggest the formation of an abscess that requires surgical intervention.
The procedure for incision and drainage of a deep abscess in the lumbar, sacral, or lumbosacral spine involves several critical steps to ensure effective treatment. First, the patient is positioned appropriately to allow access to the affected area of the back. The skin over the abscess site is then cleansed and prepared using antiseptic solutions to minimize the risk of infection. Following this, a surgical incision is made through the skin directly over the abscess. The incision is carefully extended through the soft tissue layers until the fascia is reached. Once the fascia is incised, the abscess pocket is accessed. At this point, the surgeon will break up any loculations within the abscess using blunt finger dissection, which involves gently separating the tissue to allow for complete drainage of the pus. After the abscess cavity is fully opened, it is irrigated with saline or an antibiotic solution to cleanse the area and help eliminate any remaining infectious material. Depending on the size and nature of the abscess, drains may be placed within the cavity to facilitate ongoing drainage and prevent re-accumulation of fluid. Finally, the incision may be closed in layers to promote healing, or it may be packed with gauze and left open to allow for continued drainage and monitoring of the site.
After the incision and drainage procedure is completed, the patient will require careful monitoring and post-procedure care. The surgical site should be observed for signs of infection, such as increased redness, swelling, or discharge. If drains have been placed, they will need to be monitored for proper function and may require regular changes or adjustments. Pain management is also an important aspect of post-procedure care, and patients may be prescribed analgesics to manage discomfort. Instructions regarding wound care will be provided, including how to keep the area clean and dry. Follow-up appointments may be necessary to assess healing and determine if further intervention is required. Patients should be advised to report any concerning symptoms, such as fever or worsening pain, to their healthcare provider promptly.
| Short Descr | I&D ABSCESS P-SPINE L/S/LS | Medium Descr | I&D DEEP ABSCESS PST SPINE LUMBAR SAC/LUMBOSAC | Long Descr | Incision and drainage, open, of deep abscess (subfascial), posterior spine; lumbar, sacral, or lumbosacral | Status Code | Active Code | Global Days | 090 - Major Surgery | PC/TC Indicator (26, TC) | 0 - Physician Service Code | Multiple Procedures (51) | 2 - Standard payment adjustment rules for multiple procedures apply. | Bilateral Surgery (50) | 0 - 150% payment adjustment for bilateral procedures does NOT apply. | Physician Supervisions | 09 - Concept does not apply. | Assistant Surgeon (80, 82) | 1 - Statutory payment restriction for assistants at surgery applies to this procedure... | Co-Surgeons (62) | 0 - Co-surgeons not permitted for this procedure. | Team Surgery (66) | 0 - Team surgeons not permitted for this procedure. | Diagnostic Imaging Family | 99 - Concept Does Not Apply | APC Status Indicator | Inpatient Procedures, not paid under OPPS | Type of Service (TOS) | 2 - Surgery | Berenson-Eggers TOS (BETOS) | P5B - Ambulatory procedures - musculoskeletal | MUE | 2 | CCS Clinical Classification | 168 - Incision and drainage, skin and subcutaneous tissue |
This is a primary code that can be used with these additional add-on codes.
| 20700 | Add-on Code MPFS Status: Active Code APC N ASC N1 Manual preparation and insertion of drug-delivery device(s), deep (eg, subfascial) (List separately in addition to code for primary procedure) |
| 78 | Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period: it may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). when this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.) | GC | This service has been performed in part by a resident under the direction of a teaching physician | 22 | Increased procedural services: when the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). note: this modifier should not be appended to an e/m service. | 51 | Multiple procedures: when multiple procedures, other than e/m services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. the additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s). note: this modifier should not be appended to designated "add-on" codes (see appendix d). | 52 | Reduced services: under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. this provides a means of reporting reduced services without disturbing the identification of the basic service. note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 53 | Discontinued procedure: under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. this circumstance may be reported by adding modifier 53 to the code reported by the individual for the discontinued procedure. note: this modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. for outpatient hospital/ambulatory surgery center (asc) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for asc hospital outpatient use). | 54 | Surgical care only: when 1 physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. | 58 | Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period: it may be necessary to indicate that the performance of a procedure or service during the postoperative period was: (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. this circumstance may be reported by adding modifier 58 to the staged or related procedure. note: for treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78. | 59 | Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25. | 62 | Two surgeons: when 2 surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. each surgeon should report the co-surgery once using the same procedure code. if additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added. note: if a co-surgeon acts as an assistant in the performance of additional procedure(s), other than those reported with the modifier 62, during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate. | 76 | Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service. | 79 | Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.) | 80 | Assistant surgeon: surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s). | 82 | Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s). | AS | Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery | CC | Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed) | CR | Catastrophe/disaster related | ET | Emergency services | GZ | Item or service expected to be denied as not reasonable and necessary | LT | Left side (used to identify procedures performed on the left side of the body) | X4 | Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period | XS | Separate structure, a service that is distinct because it was performed on a separate organ/structure | XU | Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service |
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| 2013-01-01 | Changed | Short Descriptor changed. |
| 2011-01-01 | Changed | Short description changed. |
| 2006-01-01 | Added | First appearance in code book in 2006. |
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