Eli's Rehab Report

Question: My physiatrist does what we call baclofen pump trials, in which the patient comes to a hospital as an outpatient. The physiatrist injects the baclofen through a lumbar puncture and observes the patient for 8-10 hours before discharging him. This procedure determines whether the patient would be a candidate for a baclofen pump insertion, which would be performed by a neurosurgeon. How should I report this?


California Subscriber


Answer: You should focus on the code for the injection procedure: 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 injection of either the epidural or subarachnoid (also known as intrathecal or via a lumbar puncture). 

Keep in mind: If your physiatrist performs an additional E/M service that is significant and separately identifiable from the pre- and postprocedure services, you may also 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 choose your E/M code from the appropriate location category--such as CPT 99201 - 99205 for a new patient or 99211-99215 for an established patient in an office or outpatient hospital setting, or 99221-99223 for initial hospital care.