Neurology & Pain Management Coding Alert

Provider will typically make decision to perform puncture during E/M.

Coders who are filing spinal puncture claims need to be careful — or that claim could be full of holes.

Why? In order to successfully code a spinal puncture, you have to know the reasons your physician is performing the procedure in order to report the correct code. Also, there will be some pre-procedure services that will warrant your coding expertise.

Don’t fret, though; just read this advice on how to report spinal punctures right every time.

E/M, Imaging Can Come Pre-Puncture

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 physician will likely make the decision to perform spinal puncture after performing an office/outpatient evaluation and management (E/M) service from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) 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 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.

Know 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)

There are also 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).

Check Out This Dx Puncture Example

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

An established patient reports to the provider complaining of headache, fever, stiff neck, and neck pain. An appropriate history and exam is 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
• 99215 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 99215 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, 99215, and 80050 to represent the patient’s symptoms.