Anesthesia Coding Alert

Question: A wet tap occurred during an epidural injection for back pain and was listed as a complication on the operative note. Do we code for the wet tap in any case, or do we only code it if the patient has a complication from the wet tap and has to return to the office?

West Virginia Subscriber

Answer: A wet tap is a risk or complication associated with a spinal tap, spinal injection, or epidural. Not every wet tap requires follow-up care or results in a spinal headache that requires additional intervention. Only code for it if your provider treats a postprocedural symptom or complication related to the wet tap. For example, you can submit 62273 (Injection, epidural, of blood or clot patch) if the anesthesiologist places an epidural blood patch following a wet tap.