EM Coding Alert

Check whether the decision to move forward with a spinal tap occurred during an E/M service.

Coders know that coding procedures can be persnickety. Coding spinal punctures, aka spinal taps, correctly means reporting the reasons the physician is performing the procedure, as well as accounting for some pre-procedure services.

Find out how to report spinal punctures correctly every time.

See How Physician Made the Call to Proceed

According to the National Institutes of Health (NIH), spinal puncture is “a diagnostic procedure in the diagnosis of meningitis, subarachnoid hemorrhage, and certain neurological disorders. It is also used in the measurement of intracranial pressure and administration of medications or diagnostic agents.”

The emergency department (ED) physician will likely make the decision to perform spinal puncture after performing an ED evaluation and management (E/M) service from the 99281 (Emergency department visit for the evaluation and management of a patient that may not require the presence of a physician or other qualified health care professional) through 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making) code set.

Be observant, though; the physician might perform another E/M service — such as hospital inpatient or observation — before deciding on the procedure.

“The ED physician would usually determine the need for a spinal puncture based on the patient’s history, symptoms, and presentation. For instance, a headache with a stiff neck and fever may indicate meningitis, so a spinal puncture would help determine a definitive diagnosis,” explains Linda Martien, COC, CPC, CPMA, CRC, of Medical Revenue Cycle Management Consulting.

“If the encounter occurs in the ED, the immediate thought would be an E/M service or other diagnostic labs,” she says.

Some of the diagnostic labs your physician might consider using: a complete blood count (CBC), chemistry panel, or head computed tomography (CT) scan.

Realize Distinction Between Diagnostic, Therapeutic Punctures

Spinal punctures are of two types: diagnostic and therapeutic. During diagnostic spinal puncture, the provider obtains a sample of cerebrospinal fluid (CSF) under fluoroscopic or computed tomography (CT) imaging guidance and sends the specimen to the laboratory for examination. The provider commonly performs this procedure to rule out meningitis or a bleed in the head such as a subarachnoid hemorrhage.

If the puncture remains diagnostic throughout, then you will choose from the following codes, depending on encounter specifics:

• 62270 (Spinal puncture, lumbar, diagnostic)
• 62328 (… with fluoroscopic or CT guidance)

Less commonly in the ED, there are times when the provider needs to reduce CSF pressure on the brain by inserting a hollow needle or catheter into the subarachnoid space, usually in the lower back of the spinal column, to withdraw CSF. This procedure is also referred to as a spinal tap.

When the physician does this during a spinal puncture, it’s therapeutic and should be reported with one of the following codes, depending on encounter specifics:

• 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter))
• 62329 (… with fluoroscopic or CT guidance).

Consider This Example

To get an idea of how a spinal puncture in the ED might look, check out this example of diagnostic spinal puncture from Martien:

A patient reports to the ED complaining of headache, fever, stiff neck, and neck pain. An appropriate history and exam are performed. The physician decides to perform a diagnostic spinal puncture to determine if the patient has spinal meningitis or to rule out other pathologies. The physician also orders laboratory studies. Notes indicate that the physician performed high-level medical decision making (MDM) during the E/M portion of the encounter.

For this encounter, you would report:

• 62270 for the spinal puncture
• 99285 (Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/ or examination and high level of medical decision making) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99285 to show that it was a significant and separately identifiable service from the puncture
• R51.9 (Headache, unspecified), R50.9 (Fever, unspecified), and M54.2 (Cervicalgia) appended to 62270, 99283, and 80050 to represent the patient’s symptoms.