Question: In a patient with a tunneled spinal epidural catheter, our physician did a revision procedure. During the scheduled follow-up visits, our physician checked the patency and functioning of the catheter and also did a general examination. How can we report the services for the follow-up examination?
Virginia Subscriber
Answer: From the description shared, it is evident that your provider had done a revision of the spinal catheter.
Look for laminectomy: You should check the operative note to confirm if your provider did a laminectomy during the revision. Depending upon whether a laminectomy was done, you should submit code 62350 (Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy) or 62351 (… with laminectomy) for revision of a tunneled epidural catheter.
Note the difference in global periods: Code 62350 has a 10-day global period, and 62351 has a 90-day global period.
Check the follow-up schedule: If the patient returns for follow-up during the global period, submit code 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure). Otherwise, you report the appropriate-level E/M service for an established patient based on the documentation requirements.
