tci E/M Coding Alert - 2023 Issue Q4

Procedure Perfection: Look to E/M First for Spinal Tap Encounters

Check whether the decision to move forward with a spinal tap occurred during an E/M service. Coders know that coding procedures can be persnickety. Coding spinal punctures, aka spinal taps, correctly means reporting the reasons the physician is performing the procedure, as well as accounting for some pre-procedure services. Find out how to report spinal punctures correctly every time. See How Physician Made the Call to Proceed According to the National Institutes of Health (NIH), spinal puncture is “a diagnostic procedure in the diagnosis of meningitis, subarachnoid hemorrhage, and certain neurological disorders. It is also used in the...

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