Neurology & Pain Management Coding Alert

Question: Our surgeon placed a lumbar drain and this was left intact for several days. How can we report this? Our surgeon also provided follow up in this patient.

Colorado Subscriber

Answer: The correct code for lumbar drain placement is 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]), which carries a zero global day period. That means you can report any other follow-up evaluation and management service as long as you have documentation to support the service and if the follow-up takes place on a different day from the drain placement. Subsequent hospital care codes are bundled into 62272.

E/M option: If documentation supports that the E/M service was separately identifiable and significant from the pre- and post-procedure work, you can submit an E/M code such as 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components ...). Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional during a postoperative period).