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Anesthesia Coding Alert

Meet and Beat the Lumbar Puncture Challenge

Published on Wed Jan 01, 2003

Focusing on three areas related to diagnostic lumbar punctures and similar procedures will help you code these claims correctly, even though determining the best anesthesia code for them has challenged coders for years. CPT Codes 2001's addition of CPT 00635 (Anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture) helped the situation but didn't cure it. Some carriers are slow to accept new codes, and a growing number of anesthesiologists perform the procedure represented by 00635 themselves.

Coding Depends on the Anesthesiologist's Role in the Procedure

One of the biggest challenges associated with billing for lumbar punctures is determining whether you should bill the service as an anesthesia charge or as a flat-fee surgical charge, says Tonia Raley, CPC, claims manager for the medical billing firm Medical Information Systems in Phoenix. "Anesthesiologists are asked to perform these procedures fairly often, as they have had extensive training in placement and management of these types of procedures," she explains.

Anesthesiologists perform most diagnostic lumbar punctures under a local anesthetic rather than general anesthesia, Raley says. If the physician performs the puncture under a local anesthetic, he or she is the only one present. Because the professional performing the spinal tap is usually able to provide adequate local anesthesia for the procedure, you should only bill the procedure no separate fee for anesthesia because none was given. But if special circumstances apply (such as treatment of children, severely mentally retarded adults or patients with delirium) and your group administers an anesthetic as well as performs the procedure, two physicians must be present during the procedure one to perform the lumbar puncture and the other to provide monitored anesthesia care (MAC) or general anesthesia.

In that scenario, bill with the appropriate anesthesia code for the physician providing anesthesia (see below for example codes), along with type-of-service "07" for "anesthesia services." The anesthesiologist who performs the procedure bills it as a flat-fee service (otherwise known as a surgical service) with the appropriate CPT code and type-of-service "02" for "surgical procedure." (Insurance forms include a key designating the different types of service, so you can place the appropriate number in the form's type-of-service box.)

Know All Your Coding Options

Once you know whether you should code the physician's services as an anesthesia provider or the performing surgeon, yet another question arises: Which coding source does the carrier base its reimbursement on? Does it use the ASA Relative Value Guide, the ASA Crosswalk, or anesthesia codes rather than the surgical codes listed in CPT?

If the anesthesiologist performs the puncture, two CPT procedure codes apply: 62270* (Spinal puncture, lumbar, diagnostic) and 62272* (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]). The physician most commonly performs the diagnostic puncture (62270) under a local anesthetic, so you should not file a separate anesthesia code, Raley says. When an anesthesiologist administers anesthesia during the procedure, he or she usually bills 00635 (Anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture) with the appropriate base and time units.

A unique situation arises when a neurosurgeon or cardiac surgeon requests the anesthesiologist to place a spinal fluid drain in the lumbar area. This is a separate procedure the anesthesiologist performs in addition to anesthesia administration for the surgical procedure, Raley says. The anesthesiologist places a drain to help during surgery for decompression of the brain and for postoperative management. Because the drain placement is a separate service, report 62272 in addition to the applicable anesthesia code for surgery.

"Spinal catheters are also used for postoperative management of some thoracic aortic aneurysms and are often inserted by the anesthesiologist," Raley says. "The anesthesiologist may charge for this in addition to the anesthesia services by appending modifier -59 (Distinct procedural service) to the procedure code and billing with a type-of-service '02' for surgical procedure."

If an anesthesiologist administers anesthesia during a diagnostic lumbar puncture, four codes are available for carriers that accept ASA codes: 00635, 00820 (Anesthesia for procedures on lower posterior abdominal wall), **02100 (Anesthesia for diagnostic or therapeutic nerve blocks and injections [when block or injection is performed by a different provider]) and **02101 (Anesthesia for diagnostic or therapeutic nerve blocks and injections patient in the prone position [when block or injection is performed by a different provider]).

When you consider these ASA codes, note two important things about **02100 and **02101:

  • These are ASA codes for anesthesia services related to punctures and blocks, not CPT codes. The ASA codes previously assigned to these descriptors (01961 and 01962) are now in CPT but deal with obstetric anesthesia instead of nerve blocks and injections.
  • ASA **02100 and **02101 are double-starred procedure codes. Medicare and other government agencies do not recognize double-starred procedure codes, and they do not appear in the anesthesia section of CPT. When you are filing the claim with a government agency such as Medicare, you would use an alternative ASA code such as 00820 or 00635 for the procedure, Raley says.

    If the carrier only accepts CPT codes for anesthesia services, billing with the newer code 00635 is more accurate than using 00820.

    Document the Need for Anesthesia

    Although code 00635 was added to the anesthesia section of CPT in 2001, carriers are often slow to accept new or revised codes. For example, many carriers, especially those dealing with workers' compensation cases, are slow to update their systems with new codes, says Tammy Caldwell, anesthesia coding team leader for Northern Colorado Professional Services in Fort Collins. The biggest problem in billing 00635, some practitioners believe, lies in justifying the need for anesthesia inserting a small needle in the back rarely requires anesthesia services unless there are exceptional circumstances, so be prepared to document thoroughly why the patient needed the anesthesia.

    If your carrier still doesn't accept code 00635, find out why. Is it not covered because the carrier considers it to be a medically unnecessary service, or is the carrier unable to process the coding? If an inability to process the code is the problem, learn what the carrier needs to process the claim. If the carrier's concern is with medical necessity, substantiate it with documentation of the procedure so you can be reimbursed under the proper code (00635) instead of resorting to alternatives such as 00300 (Anesthesia for all procedures on the integumentary system, muscles and nerves of head, neck, and posterior trunk, not otherwise specified) or 00630 (Anesthesia for procedures in lumbar region; not otherwise specified).

    "Any lumbar puncture walks the line between anesthesia and pain management," Caldwell says. "It's always difficult to get adequate reimbursement because carriers don't like it when you give anesthesia for these types of procedures. Knowing the correct codes and documenting the situation is imperative."

     

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