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Wet taps

  1. Default Wet taps
    Medical Coding Books

    If a wet tap occurs during an epidural injection for back pain and is listed as a complication on the OP note, is the wet tap coded or is it only coded if the patient has a complication from the wet tap and has to return to the office?

    There is a disagreement among co-workers. Please include rationale or references.


  2. #2
    Duluth, Minnesota
    ok, the risk of sounding ignorant....
    what's a wet tap? what CPT code is it?

    (from what I'm reading, it appears the wet tap is a "mistake", a puncture - that wasn't meant to happen - so I'm not clear "why" you'd code it - let alone what the code is! - unless, is there something you do to fix the error/complication?)
    Last edited by dmaec; 02-16-2009 at 07:53 AM.
    Donna, CPC, CPC-H

  3. Default
    This is something I ran across when I first stated coding and wanted to see how other coders handled it. If memory serves, it has something to do with an accidental puncture resulting in the withdrawal of spinal fluid and it can cause severe headaches. My supervisor said not to code it unless the patient had to come back for treatment. I don't think there is a specific code for it so, I think you would use a complication code.

  4. #4
    Yes, you're correct, a wet tap is a risk/complication of a spinal tap, spinal, or epidural. I do not dx code for it unless my provider is treating a post procedural symptom/complication to the wet tap (i.e. performing a blood patch or an evaluation and management). Not every wet tap requires follow up care or results in a spinal headache requiring additional intervention.

    Julie, CPC

  5. #5
    Duluth, Minnesota
    Default it's not a procedure - it's an accident... (that's what I thought)... I guess then, you'd be coding a dx for the problem, (perhaps).. and any follow-up/fix that might be needed..
    I thought you were looking for a CPT code for the "accident"..
    Donna, CPC, CPC-H

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