# lumbar puncture w/ methotrexate injection



## amandahollis80

What code do I assign for the following scenario? 

Our radiologist performed the lumbar puncture.

An oncologist then administered the methotrexate. 

I bill for the radiologist only. We want to code for doing the work of the lumbar puncture. What codes can we assign for this scenario?


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## cblack712

Unless a lumbar puncture was obtained for diagnostic purposes from a separate puncture site the only code that you could use is the guidance (usually 77003) as the 62270 is bundled with the methotrexate injection. It isn't beneficial to the radiologist, however it seems that Radiologists are getting the short end of the stick more and more here lately.


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## GAcoder74

*Cpc*

We use CPT 62272, 77003 when coding a lumbar puncture with methotrexate injection -- injection not performed by Rad.


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## pepe

*Rt/cpc*

if the radiologist was doing the procedure could you use CPT 96450 and if so what other procedure codes?


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## cblack712

Per Dr Z.'s Interventional Radiology Coding Reference - 
"Add code 62270 only if CSF fluid is removed via a separate punture site during the procedure for a diagnostic study. DO NOT CODE 62270 additionally if CSF fluid removal is performed via the initial needle placement used for chemotherapy administration" 

GACoder - the use of 62270 would be inappropriate unless you are obtaining a CSF collection via a seperate site. 

pepe - if the radiologist does the injection you would use the 96450 and 77003 (or whatever type of guidance is being used - almost always it is the 77003)


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## donnajrichmond

ahollis said:


> What code do I assign for the following scenario?
> 
> Our radiologist performed the lumbar puncture.
> 
> An oncologist then administered the methotrexate.
> 
> I bill for the radiologist only. We want to code for doing the work of the lumbar puncture. What codes can we assign for this scenario?



You have a problem.  Your radiologist and oncologist need to discuss this situation and come to a decision about who will bill. 
The appropriate code is 96450 - intrathecal chemotherapy injection - and it includes the spinal puncture. 
If the oncologist bills 96450 and the radiologist bills 62270 or 62272, then the patient is being double billed for the spinal puncture.  If I were the patient I'd be angry!

You have several choices: 

the oncologist performs the LP and administers the methotrexate and bills 96450 (no radiologist involvement) 
the radiologist performs the LP and administers the methotrexate and bills 96450 (no oncologist involvement)
the radiologist performs the LP, the oncologist administers the methotrexate; radiologist bills 96450 and pays the oncologist
the radiologist performs the LP, the oncologist administers the methotrexate; oncologist bills 96450 and pays the radiologist.
If fluoro guidance is used (hopefully!) that can be coded separately by whomever is in the room providing that guidance.

(Edited to add that #3 and 4 above mean that the one who bills is now liable for the other portion which he did not actually do - I'd double check with my malpractice attorney before choosing either one of those.)


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## pepe

*Rt/cpc*

Billing for radiologist we used 96450 only. We received a denial from medicare : Payment adjusted because this procedure/service is not paid seperately. Should it be billed with 77003 also?


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## donnajrichmond

pepe said:


> Billing for radiologist we used 96450 only. We received a denial from medicare : Payment adjusted because this procedure/service is not paid seperately. Should it be billed with 77003 also?



"not paid separately" indicates that it is bundled.  What other codes did you bill? 

If fluoro guidance was used and documented, you can code 77003


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## dpeoples

I agree with donna, I think you have an issue with the radiologists codes coinciding with the oncologists codes at the payor. I wonder what codes are being billed for the onco? This could be a case where whoever bills first gets paid, which is neither correct nor cost effective in the long run.

This is clearly not a diagnostic LP so, 62270/72 should not be billed for the radiologist. All you have is fluoro (77003). If the onco is injecting, all they should bill for is 96450. I can almost guarantee that both will have to have the case(s) reviewed/appealed when billing to medicare.


HTH


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## ptrautner

Dr Z would concur that they need to come to agreement....


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