# Attempted spinal tap



## mmoore70 (Mar 20, 2013)

ER doc documented "after sterile prep, several attempts were made but unable to obtain fluid" for spinal tap procedure.
Would I charge for the attempted spinal tap as 62270 w/modifier 52 or would I just include in my E/M level? 
Diagnosis was possible meningitis, but final dx was Altered Mental Status, Headache and patient transferred to another facility.
Thanks!!


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## msekarinfo (Mar 20, 2013)

phybilling1 said:


> ER doc documented "after sterile prep, several attempts were made but unable to obtain fluid" for spinal tap procedure.
> Would I charge for the attempted spinal tap as 62270 w/modifier 52 or would I just include in my E/M level?
> Diagnosis was possible meningitis, but final dx was Altered Mental Status, Headache and patient transferred to another facility.
> Thanks!!




Procedure unsuccessful
Code E/M level only


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## mmoore70 (Mar 21, 2013)

Thanks for looking at this for me!! 
Do you know of any coding websites for attempted procedures not successful guidelines? I have these situations alot, as in attempted temporary pacemaker, attempted central line insertions, and intubations. I love ER coding but can get quite confusing and constantly questioning my decisions when it comes to coding these. 
Thanks again for the help!


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## mitchellde (Mar 21, 2013)

the procedure should be billed as the procedure was completed, just no fluid obtained.  This is still a completed procedure.


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## Mojo (Mar 21, 2013)

phybilling1 said:


> Thanks for looking at this for me!!
> Do you know of any coding websites for attempted procedures not successful guidelines? I have these situations alot, as in attempted temporary pacemaker, attempted central line insertions, and intubations. I love ER coding but can get quite confusing and constantly questioning my decisions when it comes to coding these.
> Thanks again for the help!



http://www.supercoder.com/coding-newsletters/my-pediatric-coding-alert/modifier-is-key-to-optimal-lumbar-puncture-coding-article

A completed procedure can be billed whether or not it was successful. Modifier -52 isn't needed unless the EDP partially eliminated or reduced the procedure. Multiple attempts involve additional work, time and risk and should be reimbursed.


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## mmoore70 (Mar 22, 2013)

Thanks for all the replies and help!! Yes after further research, I actually charged for the procedure without any modifier because the space was entered and this would be considered a completed procedure even though the final result was not obtained. 
Thanks again!!


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## Amanda__ (Apr 10, 2013)

I code both procedure and visit even though sometimes the doctors are unable to get the  spinal fluid or the fluid may too bloody when performing the puncture


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