How To Use CPT Code 62328

CPT 62328 describes the procedure of spinal puncture, specifically lumbar puncture, with the guidance of fluoroscopy or CT imaging. This article will cover the description, official details, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 62328?

CPT 62328 is used to describe the specific procedure of spinal puncture, also known as lumbar puncture, with the guidance of fluoroscopy or CT imaging. This procedure involves obtaining a sample of cerebrospinal fluid (CSF) from the spinal cord for diagnostic purposes. It is commonly performed to rule out meningitis or assist in the diagnosis of cerebral palsy.

2. Official Description

The official description of CPT code 62328 is: ‘Spinal puncture, lumbar, diagnostic; with fluoroscopic or CT guidance.’

3. Procedure

1. The patient is positioned on their side with their knees pulled up to the chest or in a sitting position, leaning forward on a stable surface.
2. The provider administers a local anesthetic at the proposed puncture site, infiltrating the skin and deeper tissue.
3. The provider identifies the space between the second and third or third and fourth lumbar vertebrae and marks it using a surgical marker.
4. Under the guidance of fluoroscopy or CT imaging, the provider inserts a spinal needle, taking care to avoid injury to nearby blood vessels.
5. The provider advances the needle until cerebrospinal fluid (CSF) starts to leak out.
6. Approximately 8 to 15 mL of CSF is collected and sent to the pathology laboratory for further analysis.
7. The provider flushes the puncture site with sterile saline and applies gauze at the site of needle insertion.

4. Qualifying circumstances

CPT 62328 is performed when a sample of cerebrospinal fluid (CSF) needs to be obtained for diagnostic purposes. It is commonly used to rule out meningitis or assist in the diagnosis of cerebral palsy. The procedure must be performed with the guidance of fluoroscopy or CT imaging to ensure accurate needle placement and avoid injury to nearby blood vessels.

5. When to use CPT code 62328

CPT code 62328 should be used when performing a lumbar puncture with the guidance of fluoroscopy or CT imaging. It is important to note that this code should not be reported in conjunction with codes 77003 or 77012. If ultrasound or MRI guidance is used instead, different codes should be used (76942 or 77021, respectively).

6. Documentation requirements

To support a claim for CPT 62328, the provider must document the following information:

• Patient’s diagnosis or reason for the lumbar puncture
• Use of fluoroscopic or CT guidance during the procedure
• Date and time of the procedure
• Amount of cerebrospinal fluid (CSF) collected
• Any complications or adverse events
• Signature of the provider performing the procedure

7. Billing guidelines

When billing for CPT 62328, ensure that the procedure is performed with the guidance of fluoroscopy or CT imaging. It should not be reported in conjunction with codes 77003 or 77012. It is important to consider the location of the testing and use the appropriate modifiers when necessary. For therapeutic purposes, a different code (62329) should be used. For diagnostic and therapeutic spinal puncture without imaging guidance, different codes (62270 and 62272) should be used, respectively.

8. Historical information

CPT 62328 was added to the Current Procedural Terminology system on January 1, 2020. There have been no updates or changes to the code since its addition.

9. Examples

1. A provider performs a lumbar puncture with fluoroscopic guidance to obtain a sample of cerebrospinal fluid (CSF) for diagnostic purposes in a patient suspected of having meningitis.
2. Under CT imaging guidance, a provider performs a lumbar puncture to assist in the diagnosis of cerebral palsy in an infant.
3. Using fluoroscopy, a provider performs a lumbar puncture to rule out meningitis in a patient presenting with severe headache and fever.
4. A provider performs a lumbar puncture with CT guidance to obtain a sample of cerebrospinal fluid (CSF) for further analysis in a patient with suspected neurologic infection.
5. Under fluoroscopic guidance, a provider performs a lumbar puncture to assist in the diagnosis of a rare neurological disorder in a patient with unexplained symptoms.
6. A provider performs a lumbar puncture with CT imaging guidance to obtain a sample of cerebrospinal fluid (CSF) for diagnostic purposes in a patient with suspected central nervous system infection.
7. Using fluoroscopy, a provider performs a lumbar puncture to rule out meningitis in a patient with symptoms of severe neck stiffness and headache.
8. A provider performs a lumbar puncture with CT guidance to assist in the diagnosis of a suspected spinal cord tumor in a patient with progressive neurological symptoms.
9. Under fluoroscopic guidance, a provider performs a lumbar puncture to obtain a sample of cerebrospinal fluid (CSF) for further analysis in a patient with suspected autoimmune encephalitis.
10. A provider performs a lumbar puncture with CT imaging guidance to assist in the diagnosis of a suspected subarachnoid hemorrhage in a patient with sudden-onset severe headache.