Wiki Attempted spinal tap

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mmoore70

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ER doc documented "after sterile prep, several attempts were made but unable to obtain fluid" for spinal tap procedure.
Would I charge for the attempted spinal tap as 62270 w/modifier 52 or would I just include in my E/M level? :confused:
Diagnosis was possible meningitis, but final dx was Altered Mental Status, Headache and patient transferred to another facility.
Thanks!!
 
phybilling1 said:
ER doc documented "after sterile prep, several attempts were made but unable to obtain fluid" for spinal tap procedure.
Would I charge for the attempted spinal tap as 62270 w/modifier 52 or would I just include in my E/M level? :confused:
Diagnosis was possible meningitis, but final dx was Altered Mental Status, Headache and patient transferred to another facility.
Thanks!!
Click to expand...


Procedure unsuccessful
Code E/M level only
 
Thanks for looking at this for me!!
Do you know of any coding websites for attempted procedures not successful guidelines? I have these situations alot, as in attempted temporary pacemaker, attempted central line insertions, and intubations. I love ER coding but can get quite confusing and constantly questioning my decisions when it comes to coding these.
Thanks again for the help!
 
phybilling1 said:
Thanks for looking at this for me!!
Do you know of any coding websites for attempted procedures not successful guidelines? I have these situations alot, as in attempted temporary pacemaker, attempted central line insertions, and intubations. I love ER coding but can get quite confusing and constantly questioning my decisions when it comes to coding these.
Thanks again for the help!
Click to expand...

http://www.supercoder.com/coding-newsletters/my-pediatric-coding-alert/modifier-is-key-to-optimal-lumbar-puncture-coding-article

A completed procedure can be billed whether or not it was successful. Modifier -52 isn't needed unless the EDP partially eliminated or reduced the procedure. Multiple attempts involve additional work, time and risk and should be reimbursed.
 
Thanks for all the replies and help!! Yes after further research, I actually charged for the procedure without any modifier because the space was entered and this would be considered a completed procedure even though the final result was not obtained.
Thanks again!!
 
I code both procedure and visit even though sometimes the doctors are unable to get the spinal fluid or the fluid may too bloody when performing the puncture
 
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