Pain Management Coding Alert

Published on Thu Sep 01, 2016 PDF

Question: Our physician completed a revision of a tunneled spinal epidural catheter. The patient was asked to come for a follow-up visit, during which the patency and functioning of the catheter was checked in addition to the patient’s general examination. How can we report the follow-up examination?

Virginia Subscriber

Answer: Depending upon whether the physician did a laminectomy during the revision, you should submit code 62350 (Implantation, revision or repositioning of tunneled intrathecal or epidural catheter, for long-term medication administration via an external pump or implantable reservoir/infusion pump; without laminectomy) or 62351 (… with laminectomy) for revision of a tunneled epidural catheter.

Follow-up exams are common after such catheter revisions. Code 62350 has a 10-day global period, and 62351 has a 90-day global period.

If the patient returns for follow-up during the global period, submit code 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason[s] related to the original procedure). Otherwise, you report the appropriate-level E/M service for an established patient based on the documentation requirements.