Neurosurgery Coding Alert

Question: Our surgeon recently performed a consult with findings that necessitated a spinal tap on the same day. We used the same diagnosis code for the consultation and the spinal tap, but Medicare rejected payment on the consultation (but paid for the spinal tap). What did we do wrong?

Michigan Subscriber

Answer: When reporting an E/M service (such as a consult) and a minor procedure (such as a spinal tap) on the same date of service, you must be sure to append 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 E/M service code. This informs the insurer that the E/M service was separate and distinct or, as in your case, led to the decision to perform the procedure.

You may use the same diagnosis for both the consult and spinal tap if the same diagnosis applies to both services.

For example, a patient arrives for a consult because of a sudden, severe headache. The surgeon assigns a primary diagnosis of 784.0 (Headache), which she links to the consult (for example, 99243, Office consultation for a new or established patient ...). However, to rule out the possibility of meningitis or subarachnoid bleeding, the surgeon opts to perform a spinal tap (62270, Spinal puncture, lumbar, diagnostic) in addition to the E/M service. Because the headache diagnosis prompted the spinal tap, you may use the same ICD-9 code (784.0) to support the spinal tap. To demonstrate that the E/M service was not simply a routine pretest service, you must append modifier -25 to the consult code, which you should claim in addition to the spinal tap.