Lumbar Puncture
Lumbar puncture, [diagnostic / therapeutic]
[Fever and meningismus concerning for meningitis / Sudden-onset headache concerning for subarachnoid hemorrhage / Suspected idiopathic intracranial hypertension / Suspected CNS malignancy] requiring lumbar puncture for [CSF analysis / CSF analysis and therapeutic drainage].
Informed consent was obtained from the [patient / patient's surrogate] after discussion of risks, benefits, and alternatives.
[***, MD/DO]
Local: [X] mL 1% lidocaine without epinephrine[ and topical EMLA cream]
The [L3-4 / L4-5] interspace was accessed on the [first / second / third] attempt. Opening pressure was [X] cmH2O in the lateral decubitus position. CSF appeared [clear and colorless / xanthochromic / bloody / turbid / cloudy]. [X] mL of CSF was collected in [four / three] numbered tubes. [An additional [X] mL was drained for therapeutic pressure reduction.] [Closing pressure was [X] cmH2O.]
A time-out was completed confirming the patient, procedure, and site. Pre-procedure CT head [showed no mass effect, midline shift, or evidence of herniation / was not obtained given a nonfocal neurologic examination and no clinical signs of elevated intracranial pressure].
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, with the line between the iliac crests marking the L4 spinous process or L4-5 interspace. The [L3-4 / L4-5] interspace was selected as the puncture site.
The lower back was prepped with [povidone-iodine / chlorhexidine] and draped in sterile fashion. Sterile gloves were worn. The skin and subcutaneous tissue were infiltrated with [X] mL of 1% lidocaine.
A [20-gauge / 22-gauge] spinal needle with stylet in place was advanced in the midline, directed slightly cephalad toward the umbilicus, with the bevel oriented parallel to the longitudinal dural fibers. A subtle loss of resistance was felt on entry into the thecal sac. The stylet was removed, and CSF return was confirmed.
Opening pressure was measured with a manometer with the patient in the lateral decubitus position. CSF was collected into numbered tubes with [X] mL per tube. The stylet was replaced, the needle was withdrawn, and firm pressure was applied to the puncture site.
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 for RBC comparison with tube 1
[Additional: [cytology / oligoclonal bands / VDRL / cryptococcal antigen / PCR panel]]
None
The patient tolerated the procedure well. The patient was monitored for post-dural puncture headache. CSF results will be followed and communicated to the primary team.
Epic SmartPhrase Version
PROCEDURE: Lumbar puncture, [diagnostic / therapeutic]
INDICATION: *** requiring lumbar puncture for [CSF analysis / CSF analysis and therapeutic drainage].
CONSENT: Informed consent obtained from the [patient / surrogate] after discussion of risks, benefits, and alternatives.
PERFORMED BY: ***, MD/DO
ANESTHESIA: Local: *** mL 1% lidocaine without epinephrine
FINDINGS: [L3-4 / L4-5] interspace accessed on *** attempt. Opening pressure *** cmH2O (lateral decubitus). CSF appeared ***. *** mL collected in *** tubes. [Closing pressure *** cmH2O.]
PROCEDURE DETAILS:
Time-out completed. Pre-procedure CT head: ***.
Patient positioned *** with spine maximally flexed. Iliac crest line identified at L4. [L3-4 / L4-5] interspace selected.
Back prepped with *** and draped in sterile fashion. *** mL 1% lidocaine infiltrated at puncture site. *** gauge spinal needle advanced in midline, bevel parallel to dural fibers, slight cephalad angulation. Loss of resistance on thecal sac entry. Stylet removed, CSF return confirmed. Opening pressure measured by manometer. CSF collected in numbered tubes, *** mL each. Stylet replaced, needle withdrawn, pressure held.
EBL: None
SPECIMENS:
- Tube 1: cell count
- Tube 2: protein/glucose
- Tube 3: Gram stain/culture
- Tube 4: cell count
[Additional: ***]
COMPLICATIONS: None
POST-PROCEDURE PLAN: Tolerated well. [Lying flat x1 hour / Monitored for post-dural puncture headache]. CSF results to be followed and 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]. The results were communicated to the primary team for clinical correlation. [[Repeat lumbar puncture / CT angiography] was recommended given ongoing concern for subarachnoid hemorrhage.]
Elevated Opening Pressure (IIH / Therapeutic)
Opening pressure was elevated at [X] cmH2O. [X] mL of CSF was drained therapeutically until closing pressure reached [X] cmH2O. The patient reported [improvement / no change] in headache following drainage. Consultation with [neurology / neurology and ophthalmology] was requested for further management of elevated intracranial pressure.
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.
- Normal opening pressure is 8 to 20 cmH2O.
- Orient the bevel parallel to the longitudinal dural fibers to minimize dural fiber disruption.
- If chlorhexidine is used, let it dry completely before needle insertion, given the proximity to the thecal sac.
- Xanthochromia after a traumatic tap may indicate true SAH. If SAH remains a concern, repeat LP or CT angiography may be warranted.
Documentation & Reimbursement Considerations
- Primary service: Report Lumbar Puncture as the primary service when it is the definitive operation performed.
- Diagnostic lumbar puncture (1.19 wRVU, 0-day global) and therapeutic lumbar puncture for CSF drainage (1.54 wRVU), for example in idiopathic intracranial hypertension, are separate services. 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 (0.59 wRVU add-on) or CT guidance 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 the appropriate modifier appended to 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.