Neurosurgery Coding Alert

Question: Our neurologist did a spinal tap for a patient who reported to the ED with pain in legs and burning sensation. The patient had undergone a spinal surgery around seven days ago. How do we report this?

Ohio Subscriber

Answer: You report the ED visit and the lumbar puncture along with appropriate modifiers to show that they were distinct from the initial surgical procedure. You report code 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision making of low complexity …) with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period), and 62270 (Spinal puncture, lumbar, diagnostic) for the lumbar puncture. Here, your neurologist has a diagnostic intention when doing the spinal tap. You append modifier 79 (Unrelated procedure or service by the same physician during the postoperative period) to 62270 to imply that the spinal tap was a distinct service.

If the neurologist performs this service and not the surgeon, than the E/M service is reported with 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) modifier and spinal tap without modifier.