Neurosurgery Coding Alert

Know when diagnostic puncture turns surgical.

Last month, we discussed the issue of spinal punctures and the coding conventions surrounding the procedure.

This month, we’re going to put the elements of that discussion into action with a pair of clinical coding examples involving spinal punctures.

Diagnostic Spinal Puncture

To get an idea of how a diagnostic spinal puncture scenario might look, check out this example from Linda Martien, COC, CPC, CPMA, CRC, of Medical Revenue Cycle Management Consulting:

An established patient reports to the neurosurgeon complaining of headache, fever, stiff neck, and neck pain. An appropriate history and exam is performed. The physician decides to perform a diagnostic spinal puncture to determine if the patient has spinal meningitis or to rule out other pathologies. The physician also orders a general health panel. Notes indicate that the physician performed low-level medical decision making (MDM) during the E/M portion of the encounter.

For this encounter, you would report:

• 62270 (Spinal puncture, lumbar, diagnostic) for the spinal puncture 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99213 to show that it was a significant and separately identifiable service from the puncture
• R51.9 (Headache, unspecified), R50.9 (Fever, unspecified), and M54.2 (Cervicalgia) appended to 62270 and 99213 to represent the patient’s symptoms.

Therapeutic Spinal Puncture

To get an idea of how a therapeutic spinal puncture scenario might look, check out this example from Gregory Przybylski, MD, MBA, Chairman of Neuroscience at the Hackensack Meridian Health Neuroscience Institute at JFK University Medical Center in Edison, New Jersey.

An established patient has symptoms of gait impairment, confusion and urinary incontinence. An appropriate history and exam is performed. CT imaging reveals enlarged ventricles but cerebral volume loss as well. The physician is concerned about normal pressure hydrocephalus. A high volume therapeutic spinal puncture without image guidance is performed to assess whether symptoms improve with reduction in CSF volume. Moderate level medical decision making is documented.

For this encounter, you would report:

• 62272 (Spinal puncture, therapeutic, for drainage of cerebrospinal fluid (by needle or catheter)) for the spinal puncture 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) for the E/M
• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99214 to show that it was a significant and separately identifiable service from the puncture
• G91.2 ((Idiopathic) normal pressure hydrocephalus) appended to 62272 and 99214 to represent the patient’s condition.