Radiology Coding Alert

Question: Our radiologist performed a lumbar puncture and was not able to withdraw fluid, however he took intracranial pressure measurements. The clinical note of the procedure reads as follows:

“After explanation of the risks, benefits, and alternatives of the procedure, informed consent was obtained from the patient and the patient was placed prone on the fluoroscopic table. The skin and subcutaneous tissues at the proposed puncture site at L3-4 were infiltrated with a total of 3 mL of 1% lidocaine solution. Utilizing fluoroscopic guidance, a 22-gauge needle was inserted into the lumbar thecal sac at the L3-4 level. Pressure measurement revealed an intracranial pressure of 13.5 cm of water. As per the ordering physician, as the pressure was not about 20 cm of water, no removal of CSF was performed.”

How do we report this? What about the intracranial pressures that were taken? Is there a CPT code which covers the pressure measurements?

Ohio Subscriber

Answer: Your physician may perform a spinal puncture to either diagnose or treat the underlying condition. Accordingly, you will report 62270 (Spinal puncture, lumbar, diagnostic) or 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid [by needle or catheter]). Since fluoroscopy is being used to guide the needle, you also report 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural or subarachnoid]). You append modifier 26 (Professional component) to 77003 to earn for your radiologist’s contributions.

The measurement of intracranial pressures are all inclusive to 62270 code because this was going to be an unsuccessful procedure. So you do not report any codes for it.

There are two possibilities for you:

(1)  Append modifier 53 (Discontinued procedure) to 62270 if the physician doesn’t withdraw any fluid.

(2)  Don’t append a modifier to 62270 because an unsuccessful attempt still requires the same basic steps as a successful one.

You deserve payment for a tap, even if unsuccessful. The result of the puncture has no implication on reporting the procedure. For any unsuccessful tap, you report code 62270. Alternatively, your physician may decide to discontinue a puncture as it may be risky to continue the procedure. You append modifier -53 to indicate a service was discontinued.

Note: Your physician may do a single spinal puncture for both diagnosis and treatment. In this case, you should report 62272, provided your physician documents the treatment portion. 62272 has a higher RVU and will garner more payment. The RVU for 62272 is 2.51 ($85.40) while the RVU for 62270 is 2.32 ($78.93). Do not report these two codes together, except when your physician performs the two procedures on separate days.

Your physician may not succeed at each puncture. You may read in the operative note that the result of the puncture was ‘a bloody tap’ instead of spinal fluid. In this case, you would report 62270 without any modifiers. Every time your physician does an incomplete tap, he may spend more time on the puncture, be it diagnostic or therapeutic. Your physician may make multiple attempts on the puncture before finally deciding to discontinue the procedure. But these circumstances may not justify the use of modifier 22 (Increased procedural services). You may append modifier 22 only when there is ample documentation to support the complexity of the procedure.