Cracking the Code
Getting to the Point of an IVR Lumbar Puncture
Interventional radiology (IVR) uses minimally invasive image-guided procedures (such as x-ray fluoroscopy, computed tomography, magnetic resonance imaging, or ultrasound) to diagnose and treat diseases inside of the body. There is much less risk, pain, and recovery time for IVR procedures compared to open surgeries. A lumbar puncture (sometimes referred to as a spinal tap) is an example of an IVR procedure that reveals if the amount of protein, white blood cells, or myelin is too high in your body. It can also reveal if the fluid in your spine contains an abnormal level of antibodies. By analyzing this fluid, the physician can diagnose the patient with a condition.
Q: A patient enters an orthopedic office with complaints of muscle spasms/pain, stiffness, and weakness. The physician performs a fluoroscopic lumbar puncture in order to collect spinal fluid to test for certain antibodies. The patient tolerates the procedure well and is instructed to return in two months in order to review the findings.
A: ICD-10-PCS Code: 009U3ZX, Drainage of Spinal Canal, Percutaneous Approach, Diagnostic CPT Code: 62328, Spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance
Reference: CPT Assistant July 2020 page 15: Lumbar puncture diagnostic and therapeutic updates, erratum