Neurology & Pain Management Coding Alert

Intent and modifiers help to recoup your payment.
Although apparently simple, the codes for spinal punctures may pose a difficult challenge if you aren't appending the correct modifiers. You may face a situation where your physician may document an unsuccessful attempt at the spinal puncture and you'll need to lean on modifiers to accurately report the procedure. A few simple tips can boost your spinal punctures claims success.
1. Identify the Intent
Your physician may perform a spinal puncture to either diagnose or treat the underlying condition. Accordingly, you will select from the following two codes:

• 62270 (Spinal puncture, lumbar, diagnostic)
• 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]).

"Report code 62272 for therapeutic purposes when a patient needs to have a reduction in cerebral spinal fluid pressure," says Teresa Thomas, BBA, RHIT, CPC, practice manager II at St. John's Clinic (Neurosurgery) in Springfield, Mo.
"The difference in these two codes (62270 and 62272) is the intent of the procedure," adds Rena Hall, CPC, Billing/Coding, Kansas City Neurosurgery Group, Kansas City, Mo. "Code 62270 includes injection of contrasts for diagnostic testing, whereas 62272 would only be used for a therapeutic treatment."
"A lumbar puncture typically is performed to collect a sample of cerebral spinal fluid (CSF) which can help diagnose serious infections, such as meningitis; disorders of the central nervous system, such as Guillain-Barre syndrome and multiple sclerosis; or cancers of the brain or spinal cord," says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. "The spinal puncture could also be used as a diagnostic tool to measure pressure in the spinal fluid."
Watch for the overlap: Your physician may do a single spinal puncture for both diagnosis and treatment. In this case, you should report 62272, provided your physician documents the treatment portion. Code 62272 has a higher RVU and will garner more payment. The RVU for 62272 is 2.5 ($84.94) while that for 62270 is 2.32 ($78.83).
Remember that you would not bill these two codes together, however. "You would either bill for the diagnostic or the therapeutic puncture," says Thomas. "When trying to bill 62272 for MCR patients with code 62270, you will hit a CCI edit which would let you know if these two codes are bundled or if a modifier would allow these two codes to be billed together."
Exception: If your physician does the two procedures on two separate days, you can report both 62270 and 62272 as separate codes.
Code both procedures: Your physician may do two punctures on a single day at separate sessions, one for diagnosis and another subsequent one for treatment. In this case, report 62270 along with modifier 59 (Distinct procedural service ...) and also report 62272 separately. "You would be able to bill separately if the two procedures were done on two different days. Be sure your physician has documented the reason for the procedures in both," Thomas explains.
"If the spinal puncture for diagnostic purposes is performed on a different date from the spinal puncture performed for therapeutic purposes, there are no issues. The NCCI edits only come into play IF the two procedures are performed on the same beneficiary by the same provider on the same date of service," says Hammer.
Tip: Make sure you document clearly the necessity for both punctures. Include the details of the diagnostic puncture and also document the results of the same. Subsequently, document the details and reasons for the therapeutic puncture. "The therapeutic drainage of CSF can be performed for elevated intra-cranial pressures due to acute traumatic brain injury or hydrocephalus due to tumor, bleeding or malfunctioning V-P shunts," says Hammer.
2. Report Unsuccessful Punctures
Your physician may not succeed at each puncture. You may read in the procedure note that the result of the puncture was 'a bloody tap' instead of spinal fluid. In this case, you would report 62270 without any modifiers.
Reasoning: You deserve payment for a tap, even if it is unsuccessful. The result of the puncture has no implication on reporting the procedure.
3. Submit Incomplete Punctures
Your physician may decide to discontinue a puncture if continuing the procedure could be risky (such as, continuing might endanger the patient's well-being).
"A procedure, either diagnostic or therapeutic, may be discontinued in an extenuating circumstance or if the well-being of the patient was in jeopardy," says Thomas.
An incomplete service is a service that was stopped "due to the patient's inability to tolerate or a malfunction of equipment," adds Hall. Use modifier 53 (Discontinued procedure ....) with the procedure code to indicate a service was discontinued.
Example: You may read in the operative note that while undergoing a puncture to obtain a diagnostic sample of spinal fluid, the patient developed respiratory distress or numbness and tingling in the legs. The puncture was then discontinued by the physician. "You would report the procedure with CPT^® 62270 with modifier 53 letting the payer know that this procedure was discontinued," says Thomas.
Tip: You also append modifier -53 when your physician decides to discontinue the procedure due to any equipment failure or because the physician sustained a prick or other injury during the attempt. Modifier 53 implies the unexpected circumstance that necessitates the discontinuation of the puncture.
Appendix A of CPT^® explains, "Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the physician for the discontinued procedure."
Exception: You do not report a procedure that is electively discontinued. For example, your physician may decide not to perform a scheduled puncture because the patient's symptoms have completely resolved," says Hammer.