2025 CPT code 62328
(Active) Effective Date: N/A Revision Date: N/A Surgery - Surgical Procedures on the Nervous System Surgery Feed
Lumbar spinal puncture, diagnostic, with fluoroscopic or CT guidance.
Modifiers may apply depending on the circumstances of the procedure. Consult current modifier guidelines.
Medical necessity for a lumbar puncture is established when there is a clinical suspicion of conditions affecting the central nervous system, such as infection (meningitis, encephalitis), autoimmune disorders (multiple sclerosis, Guillain-Barré syndrome), or neurological conditions (cerebral palsy, subarachnoid hemorrhage). The test aids in diagnosis, guiding appropriate treatment and management of these conditions.
The physician is responsible for patient positioning, prepping and draping the puncture site, administering local anesthetic, identifying the appropriate intervertebral space, inserting the spinal needle under imaging guidance, collecting the CSF sample, and sending the sample to the lab for analysis. Post-procedure care includes flushing the puncture site and applying a dressing.
In simple words: The doctor uses imaging (like X-rays or a CT scan) to guide a needle into the lower back to collect a fluid sample from the spinal cord. This sample is tested to help diagnose problems like infections or conditions affecting the brain and spinal cord.
This CPT code, 62328, represents a diagnostic lumbar spinal puncture performed under fluoroscopic or computed tomography (CT) guidance.The procedure involves inserting a needle into the lumbar spine to obtain a cerebrospinal fluid (CSF) sample for laboratory analysis.Fluoroscopic or CT imaging ensures accurate needle placement, minimizing the risk of complications.The obtained CSF is then sent for pathological examination to aid in diagnosing conditions such as meningitis or cerebral palsy.
Example 1: A 25-year-old presents with fever, headache, and nuchal rigidity. Suspecting meningitis, the physician performs a lumbar puncture under CT guidance to obtain CSF for culture and sensitivity testing., A 40-year-old patient with suspected Guillain-Barré syndrome undergoes a lumbar puncture under fluoroscopic guidance for CSF analysis to assess for elevated protein levels and oligoclonal bands., An infant with developmental delays undergoes a lumbar puncture under fluoroscopic guidance to collect CSF for analysis to help diagnose cerebral palsy.
* Detailed history and physical examination documenting the patient's symptoms and indication for lumbar puncture.* Imaging reports (fluoroscopy or CT) showing needle placement and CSF collection.* Pathology report detailing CSF analysis results (e.g., cell count, protein levels, glucose, culture and sensitivity).* Documentation of the procedure, including needle size, depth of insertion, and amount of CSF collected.* Note of any complications or adverse events.* Informed consent.
** This code is for diagnostic lumbar puncture only.For therapeutic lumbar punctures, refer to other relevant CPT codes.Always refer to the most recent CPT codebook for the latest guidelines and updates.
- Payment Status: Active
- Modifier TC rule: Not applicable.
- Specialties:Neurology, Neurosurgery
- Place of Service:Inpatient Hospital, Outpatient Hospital, Ambulatory Surgical Center