Lumbar Puncture

CPT 62270
Approach Bedside
Add-on / Variant CPTs
  • 62272 — Therapeutic LP (CSF drainage for elevated ICP)
Preoperative Diagnosis:

[Suspected meningitis / subarachnoid hemorrhage / idiopathic intracranial hypertension / CNS malignancy / other indication for CSF analysis]

Postoperative Diagnosis:

Same

Procedure Performed:

Lumbar puncture — [diagnostic / therapeutic]

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Nurse/tech name]

Anesthesia:

Local — [X] mL 1% lidocaine without epinephrine; [topical EMLA cream if used]

Indications:

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.

Findings:

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.

Description of Procedure:

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 was 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].

Complications:

None

Specimens:

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]

Estimated Blood Loss:

None

Drains:

None — [X] mL CSF collected. [Therapeutic LP: X mL drained for ICP management.]

Disposition:

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 — .TODAY
Variants

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 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). Used for both diagnostic and therapeutic LPs — there is no separate therapeutic LP code; document volume removed 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) or CT guidance (77012) can be billed separately if 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.