Neurosurgery Coding Alert

Decision to perform puncture could be made during E/M.

Coders that aren’t careful could have holes punched in their spinal puncture claims.

Why? There are specific details to mind on each spinal puncture, from pre-procedure services your surgeon provides through to the ICD-10 codes you report for the surgery.

Read on to check out how to report spinal punctures right the first time, every time.

Spinal Puncture Decision Made After E/M, Imaging

According to the National Institutes of Health (NIH), spinal puncture is “a diagnostic procedure in the diagnosis of meningitis, subarachnoid hemorrhage, and certain neurological disorders. It is also used in the measurement of intracranial pressure and administration of medications or diagnostic agents.”

The physician will likely make the decision to perform spinal puncture after performing an office/outpatient evaluation and management (E/M) service from the 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.) Be observant, though; the physician might perform another E/M service — such as hospital inpatient or observation — before deciding on the procedure.

“The physician would usually determine the need for a spinal puncture based on the patient’s history, symptoms, and presentation. For instance, a headache with a stiff neck and fever may indicate meningitis, so a spinal puncture would help determine a definitive diagnosis,” explains Linda Martien, COC, CPC, CPMA, CRC, of Medical Revenue Cycle Management Consulting.

Differentiate Diagnostic, Therapeutic Punctures

Spinal punctures are of two types: diagnostic and therapeutic. During diagnostic spinal puncture, the provider obtains a sample of cerebrospinal fluid (CSF) under fluoroscopic or computed tomography (CT) imaging guidance and sends the specimen to the laboratory for examination. The provider commonly performs this procedure to rule out meningitis or help diagnose cerebral palsy.

If the puncture remains diagnostic throughout, then you will choose from the following codes, depending on encounter specifics:

• 62270 (Spinal puncture, lumbar, diagnostic)
• 62328 (… with fluoroscopic or CT guidance)

There are times when the provider needs to reduce CSF pressure on the brain by inserting a hollow needle or catheter into the subarachnoid space, usually in the lower back of the spinal column, to withdraw CSF. This procedure is also referred to as a spinal tap.

When the physician does this during a spinal puncture, it’s therapeutic and should be reported with one of the following codes, depending on encounter specifics:

• 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter))
• 62329 (… with fluoroscopic or CT guidance).