Neurology & Pain Management Coding Alert

Question: How should I code a spinal tap and consultation performed on the same day by the same neurologist?
                                     
Minnesota Subscriber  
Answer: First determine if the spinal tap was performed for diagnostic or therapeutic purposes. Diagnostic injections such as 62270 (spinal puncture, lumbar, diagnostic) are used mainly to help identify sources of pain or infection. Code 62263 (percutaneous lysis of epidural adhesions using solution injection [e.g., hypertonic saline, enzyme] or mechanical means [e.g., spring-wound catheter] including radiologic localization [includes contrast when administered]) may also be used for diagnostic purposes for lysis of epidural adhesions. Therapeutic injections 64400-64484 (anesthetic injections to somatic nerves), 64505-64530 (... to sympathetic nerves), 64600-64680 (neurolytic injections) or 62310-62311 (non-neurolytic epidural injections) are used to relieve pain or muscle spasms.
 
For example, a patient may have lower back pain (724.2) that physical therapy or other more conservative treatments do not alleviate. The neurologist may perform a diagnostic spinal puncture, lumbar (62270) to aid in diagnosis.
 
If the consult led to the decision for the spinal tap, the appropriate consultation code can be billed separately from 62270. According to the Centers for Medicare & Medicaid Services (CMS, formerly HCFA), "An initial consultation followed by treatment will be paid if all the criteria for a consultation are satisfied. Payment may be made regardless of treatment initiation unless a transfer of care occurs."
 
A diagnostic spinal tap is a starred procedure, which means you should bill an office-visit or hospital-visit code as well. A starred procedure is a surgical procedure that does not include associated pre- and postoperative services. Therefore, you should use the appropriate E/M  code. CPT states, "Because of the indefinite pre- and postoperative services, the usual 'package' concept for surgical services ... cannot be applied." A diagnostic spinal tap is such a procedure. You should attach modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the proper consultation code to indicate that this procedure falls within the 90-day global period.
 
Tip: If you perform the spinal tap in the office, remember to attach A4550 to bill for the appropriate surgical tray. You won't be guaranteed a payment -- most carriers consider the supplies to be included in the procedure cost -- but some will pay.