Question

CASE 12-9 Operative Report, Lumbar Puncture

LOCATION: Inpatient, Hospital

PATIENT: Larry Swope

ATTENDING PHYSICIAN: Timothy Pleasant, MD

SURGEON: Timothy Pleasant, MD

INDICATION: Vascular headache

PROCEDURE PERFORMED: Diagnostic lumbar puncture

PROCEDURE: Following Betadine prep, local anesthetic was instilled in the L3-4 (third lumbar vertebra-fourth) interspace. A #20-gauge needle was then inserted in this interspace and advanced until it entered the subarachnoid space on the second pass. Opening pressure was 110 mm (millimeter) of water. Five centimeters of crystal-clear fluid was obtained and sent to the laboratory for routine diagnostic studies, including viral culture. The patient tolerated the procedure well. He was given instructions as to how to avoid post–lumbar tap headache.

SERVICE CODE(S): _______________________________________

ICD-10-CM DX CODE(S): __________________________________

Answer 1

Answers

  CPT codes are used to describe the medical procedures performed by a healthcare provider to the patient, and ICD 10 CM codes are seven characters, alphanumeric codes used to describe the category of injury or disease.

Procedure performed for the patient: Diagnostic lumbar puncture.

CPT codes for the given procedure are:

• 62270- Spinal puncture, lumbar, diagnostic

Along with the CPT code 62270, code the injection of the contrast under fluoroscopic guidance also.

• 77003- Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural or subarachnoid).

Diagnosis of the patient: Vascular headache

ICD 10 CM code for the diagnosis is:

• G44.1- Vascular headache, not elsewhere classified