Lumbar Puncture
6227062272wRVU: 1.54 — Therapeutic LP (CSF drainage for elevated ICP)
[Suspected meningitis / subarachnoid hemorrhage / idiopathic intracranial hypertension / CNS malignancy / other indication for CSF analysis]
Same
Lumbar puncture, [diagnostic / therapeutic]
[Attending name], MD/DO
[Nurse/tech name]
Local: [X] mL 1% lidocaine without epinephrine, [topical EMLA cream if used]
The patient is a [age]-year-old [male/female] with [clinical indication: fever and meningismus / sudden onset headache / concern for subarachnoid hemorrhage / elevated ICP / CSF evaluation for malignancy] requiring lumbar puncture for CSF analysis [and/or therapeutic drainage]. Pre-procedure CT head was [obtained and showed no evidence of increased ICP / mass effect / midline shift / herniation]. The risks, benefits, and alternatives of the procedure were discussed with the patient, and informed consent was obtained.
The L[3-4 / 4-5] interspace was successfully accessed on [first / second / third] attempt. Opening pressure was [X] cmH2O ([normal 8–20 / elevated]). CSF appeared [clear and colorless / xanthochromic / bloody / turbid / cloudy]. [X] mL of CSF was collected in four numbered tubes. Closing pressure was [X] cmH2O. The patient tolerated the procedure without complication.
The patient was positioned in the [lateral decubitus fetal position / seated leaning forward] with the spine maximally flexed to open the interspinous spaces. Bony landmarks were identified by palpation: the L4 spinous process at the level of the posterior superior iliac crests. The L[3-4 / 4-5] interspace was selected as the puncture site.
The lower back was prepped with [betadine / ChloraPrep (chlorhexidine used with caution given proximity to the thecal sac)] and draped in sterile fashion. Sterile gloves were worn. The skin and subcutaneous tissue were infiltrated with [X] mL of 1% lidocaine, creating a subcutaneous wheal.
A [20-gauge / 22-gauge] spinal needle with stylet in place was advanced in the midline at the [L3-4 / L4-5] interspace, directed slightly cephalad toward the umbilicus. The needle was advanced with the bevel oriented parallel to the longitudinal dural fibers to minimize dural fiber disruption. A subtle decrease in resistance (pop) was felt upon entering the thecal sac. The stylet was removed, confirming clear CSF return.
Opening pressure was measured with a manometer in the lateral decubitus position at [X] cmH2O. [Four / three] numbered tubes were collected with [X] mL per tube: tubes 1 and 4 for cell count, tube 2 for protein and glucose, tube 3 for Gram stain and culture [and additional studies as indicated: cytology / oligoclonal bands / VDRL / cryptococcal antigen / PCR].
The stylet was replaced and the needle was withdrawn. Firm pressure was applied to the puncture site. The patient was [instructed to remain supine for 1 hour / repositioned comfortably].
None
CSF tube 1: cell count with differential
CSF tube 2: protein, glucose (concurrent serum glucose ordered)
CSF tube 3: Gram stain and culture
CSF tube 4: cell count with differential [xanthochromia comparison to tube 1]
[Additional: cytology / oligoclonal bands / specific PCR panels as indicated]
None
None. [X] mL CSF collected. [Therapeutic LP: X mL drained for ICP management.]
The patient tolerated the procedure well. Post-procedure, the patient was [instructed to lie flat for 1 hour / monitored for post-LP headache]. CSF results were communicated to the primary team as they resulted.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Lumbar puncture, diagnostic/therapeutic
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: Local: *** mL 1% lidocaine without epinephrine
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX with *** requiring LP for CSF analysis. Pre-procedure CT head: ***. Risks and benefits discussed, consent obtained.
FINDINGS: L***-*** interspace accessed on *** attempt. Opening pressure *** cmH2O. CSF appeared ***. *** mL collected in 4 tubes. No complications.
PROCEDURE:
Patient positioned in *** with spine maximally flexed. L4 spinous process identified at PSIS level. L***-*** interspace selected.
Back prepped and draped in sterile fashion. *** mL 1% lidocaine infiltrated at puncture site. *** gauge spinal needle advanced in midline, bevel parallel to dural fibers, with slight cephalad angulation. Dural pop noted. Stylet removed. Clear CSF return.
Opening pressure: *** cmH2O. Four tubes collected (*** mL each):
- Tube 1/4: cell count
- Tube 2: protein/glucose
- Tube 3: Gram stain/culture
[Additional: ***]
Stylet replaced, needle withdrawn. Pressure held.
COMPLICATIONS: None
SPECIMENS: CSF tubes 1-4 per above
DISPOSITION: Patient tolerated procedure. Lying flat x1 hour. Results communicated to primary team.
Signed: .ME, .MYDEGREE
.TODAYVariants
Traumatic Tap
CSF in tube 1 appeared bloody with clearing noted in tube 4, consistent with a traumatic tap rather than true subarachnoid hemorrhage. RBC count decreased from [X] in tube 1 to [X] in tube 4. Xanthochromia was [absent / present (if present, may indicate true SAH)]. The results were communicated to the primary team for clinical correlation. Repeat LP or CT angiography may be warranted if SAH remains a concern.
Elevated Opening Pressure (IIH / Therapeutic)
Opening pressure was elevated at [X] cmH2O (normal 8–20 cmH2O). [X] mL of CSF was drained therapeutically until closing pressure reached [X] cmH2O. The patient reported [improvement / no change] in headache following drainage. Neurology [or ophthalmology] was consulted for further management of elevated ICP.
Failed Bedside: Referred for Fluoroscopic Guidance
After [number] unsuccessful bedside attempts due to [obesity / severe degenerative disc disease / inability to position / prior lumbar surgery], the procedure was terminated without CSF collection. The patient was referred to interventional radiology for fluoroscopic- or CT-guided lumbar puncture. No complications from the attempts were observed.
Charting Tips
- Always document the pre-procedure CT head result. Performing LP without ruling out elevated ICP or mass lesion (when clinically indicated) is a major medicolegal risk. State explicitly that no contraindications were identified.
- Record the opening pressure in cmH2O with the patient in lateral decubitus. This measurement is only accurate in the lateral position, not seated. Note the position used.
- Document tube order and what was sent in each tube. Tube 4 cell count compared to tube 1 is the standard method for distinguishing traumatic tap from SAH. If xanthochromia is the concern, note whether the tube was protected from light.
Billing Tips
- Bill 62270 for diagnostic lumbar puncture (1.19 wRVU, 0-day global). Bill 62272 for therapeutic LP (1.54 wRVU) when performed specifically for CSF drainage — for example, idiopathic intracranial hypertension requiring therapeutic drainage. These are separate codes; bill based on the documented intent and clinical indication.
- Document opening pressure, CSF appearance, and tubes sent. These details establish medical necessity and are required if payer audits the claim.
- Fluoroscopic guidance (77003, 0.59 wRVU add-on) or CT guidance (77012) can be billed separately when used for a difficult LP. Document body habitus, prior failed attempts, or anatomy requiring imaging guidance.
- 0-day global: no bundled postoperative period. The LP can be billed on the same day as an E/M if a significant separately identifiable evaluation is documented with modifier -25 on the E/M.
- If performed by a resident, the attending must document supervision or co-sign the procedure note. Billing under the attending requires the attending be present for the key portions of the procedure.
General coding reference. Verify with your institution’s billing department before submitting claims.