Use These Tips to Decipher Diagnostic, Therapeutic Spinal Punctures
Remember to code differently for puncture with chemo. When a patient reports to the provider for a spinal puncture, there are any number of reasons that could have brought them there: it could be a recent injury, chronic pain, a disease — just about anything that causes spinal pain could be the impetus. Your job is identifying the type of spinal puncture as represented in the notes and choosing the correct CPT® and ICD-10-CM codes for the visit. Check out this primer on identifying diagnostic and therapeutic spinal punctures, along with a listing of appropriate codes and a couple of clinical examples. Know Spinal Puncture Purposes A spinal puncture, commonly referred to as a lumbar puncture or spinal tap, is performed to diagnose or treat various conditions affecting the brain, nerves, and spinal cords. This procedure involves inserting a needle into the lower back to obtain cerebrospinal fluid (CSF) for diagnostic testing. A therapeutic spinal puncture is performed to lessen CSF pressure. In some cases, the spinal fluid is drawn through a needle as a lumbar puncture test. In other cases, a catheter is inserted and emptied into a reservoir. A pressure reading is performed with a manometer. When coding these services, you must think about the intent behind the lumbar puncture: Is the provider diagnosing a condition or lessening symptoms by reducing pressure? Identify Signs That May Lead to Spinal Puncture A doctor may recommend a diagnostic spinal tap when a patient has symptoms like a severe headache, fever with a stiff neck, confusion, or an unexplained neurological change. A spinal puncture can diagnose infections, detect bleeding or cancer, investigate symptoms, and diagnose neurological conditions. A physician may recommend a therapeutic spinal tap to reduce pressure for a patient with hydrocephalus. A tap can help limit the widening of the ventricles in the brain. Aside from diagnostic or therapeutic purposes, a spinal tap may be done to administer chemotherapy into the central nervous system, which is reported with 96450 (Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture). Administering these drugs or biologic agents “requires a physician or other qualified health care professional work well beyond that of therapeutic drug agents (96360-96379) because the incidence of adverse patient reactions is typically greater,” per CPT®. Use These Codes for Lumbar Puncture Procedures When your provider performs a lumbar puncture, you’ll choose among the following CPT® codes, depending on encounter specifics: Check Out These Common Lumbar Puncture Dx Codes A diagnostic lumbar puncture provides a sample of CSF to analyze for the following: Patients presenting for lumbar puncture can suffer from a variety of conditions, and the ICD-10-CM codes that you might use for these patients is just as varied; however, here are some of the more common diagnosis codes associated with these patients: Consider These Clinical Examples Now that you’ve got the basics, check out these two clinical examples of lumbar puncture scenarios. The first is therapeutic, while the second is diagnostic: Example 1: A 42-year-old patient comes into the emergency department experiencing double vision, fatigue, and loss of peripheral (side) vision. With the patient having a BMI at 32.6 and being within the risk factor age range of 20-45, considering intracranial hypertension. We discussed the risks of a lumbar puncture where we can measure the current pressure of the cerebral spinal fluid. Patient agreed to proceed. Locating the L4 spinous process, we insert the needle between L3-L4 utilizing fluoroscopic guidance. Once the subarachnoid space is reached and CSF is draining, we attach the manometer and measure the pressure. Finding the pressure to be significantly higher, confirming intracranial hypertension, we elect to drain excess CSF. Once intracranial hypertension is within the healthy range of pressure, we complete the procedure. Coding: For this encounter, you’d report 62329 for the spinal puncture with G93.2 (Benign intracranial hypertension) and Z68.32 (Body mass index [BMI] 32.0-32.9, adult) appended. Note: Although this began as a diagnostic spinal puncture, the physician ended up draining the spinal fluid for more than just the diagnostic reason. This changes the procedure from diagnostic to therapeutic. Remember that the fluoroscopy guidance is bundled into this code and not billed separately. Example 2: A premature infant born at 34 weeks began exhibiting symptoms seen at this morning’s rounds. Patient has a consistent fever, vomiting with obvious irritability, and eating less. Discussed options with patients’ family on performing a spinal puncture to be able to diagnose these symptoms as it could be a wide range of bacterial to viral illness. Using a thin, hollow needle we inserted in the lumbar spaces to remove a small amount of cerebrospinal fluid for lab analysis. Labs reported viral meningitis for the patient. Antibiotics will be started as we investigate the cause of this viral illness. Coding: For this encounter, you’d report 62270 for the spinal puncture with A87.9 (Viral meningitis, unspecified) and P07.37 (Preterm newborn, gestational age 34 completed weeks) appended. Kalie Bothma, CPC, CEDC, CSAF, Medical Coder, Corewell Health
