Eli's Rehab Report

Question: My physiatrist does baclofen pump trials, in which the patient comes to a hospital as an outpatient, and the physiatrist injects the baclofen through a lumbar puncture. He then observes the patient for 8-10 hours before discharge to determine whether the patient would be a candidate for a baclofen pump insertion. How should I code this?


Montana Subscriber


Answer: You'll most likely report 62311 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; lumbar, sacral [caudal]). This code covers either epidural or the subarachnoid (also known as the intrathecal or via a lumbar puncture). 

If the physiatrist performs additional E/M services that are significant and separately identifiable from the pre- and postprocedure services, you may be able to report an E/M code with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Remember to use the appropriate E/M location category (such as, inpatient, 99221-99239; or outpatient, 99201-99215).