20610

coder21

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Question my provider feels that a 20610 is same as a lumbar puncture on the table of risk? Thoughts. Patent has DJd of the knee.
 

thomas7331

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Question my provider feels that a 20610 is same as a lumbar puncture on the table of risk? Thoughts. Patent has DJd of the knee.
"Obtain fluid from body cavity, eg lumbar puncture, thoracentesis, culdocentesis" in the table of risk falls under 'diagnostic procedures ordered', so yes, as a diagnostic procedure (aspiration) I could see that this might be moderate risk. However, as a therapeutic procedure (injection), I think it would classify under 'management options' and be considered a minor surgery, which could be low or moderate risk depending on the risk factors identified.

I would always caution, however, to refer to the instructions on the use of the table: "Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment." The selection of risk for an E&M service should be based how these factors are identified in documentation, which can vary from patient to patient, and coders/providers should not use an absolute rule for assigning risk simply based on a classification identified in the table.
 
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