ED Coding and Reimbursement Alert

When the spinal tap's incomplete, make sure your coding isn't

If you perform an unsuccessful, incomplete or difficult spinal tap, knowing when to apply a modifier is your ticket to deserved 62270 reimbursement.

When you attempt a lumbar puncture (LP), several scenarios other than a normal spinal tap (62270, Spinal puncture, lumbar, diagnostic) may occur. Here's what to report when you encounter these variations:

Unsuccessful Tap Requires No Modifier

Sometimes you can complete a spinal tap, but the results aren't want you wanted. "When you perform a lumbar puncture, your intent is to get spinal fluid," says Peter Rappo, MD, FAAP, clinical professor at Harvard Medicine School in Boston. "Anything else is not what you want."

So, how should you code if the puncture fails to produce the desired results? For instance, the needle contains blood, rather than spinal fluid. You could report 62270 without a modifier, says Diane M. Minard, CPC, a coding adviser for Dartmouth Hitchcock Medical Center in Lebanon, N.H. "The physician completed the procedure and obtained a specimen." However, since this type of sample doesn't aid in the patient's care, some groups will forego billing for the procedure.

"If the test is performed, it doesn't matter what the results are - you should still charge the same way," says Sue Downey, CPC, at North Adams Regional Hospital in North Adams, Mass. "The only time it might be different would be if the physician had to terminate the procedure." But some experts, taking public-relations issues into consideration, might agree not to code for this type of result.

Use Modifier -53 for Incomplete Tap

You need a modifier, however, when you can't complete the puncture. "If you give up trying to obtain a specimen or discontinue the procedure, you could use modifier -53 (Discontinued procedure) or modifier -52 (Reduced services) on 62270," Rappo says.

Several reasons may cause you to halt the lumbar puncture prior to completion. For instance, the patient may not remain still, making the puncture risky and impossible. Physical problems, such as respiratory difficulties, may also cause the physician to discontinue a spinal tap. In either of these cases if the procedure was discontinued due to a threat to the patient's well-being, you could append modifier -53 to 62270, Minard says. The modifier tells the payer that you had to discontinue the procedure due to extenuating circumstances or circumstances that threatened the patient's well-being.

Important: CPT indicates modifier -53 should not be used unless the procedure is discontinued after the patient has been anesthetized and/or surgically prepped in the operating suite. The surgical preparation usually involved with a lumbar puncture should meet the intent of this restriction.

Problem: These modifiers will cause the insurer to reduce payment for 62270. An incomplete tap may require more time than a complete procedure would take. You may attempt to perform the procedure multiple times before deciding to discontinue the procedure.

Check to See Whether -22 Applies

Two scenarios, however, may justify increased reimbursement. If a patient has an altered anatomy due to scoliosis or a congenital anomaly, you could appropriately use modifier -22 (Unusual procedural services), Rappo says.

Tip: Before reporting 62270-22, make sure documentation justifies the increased work. You should note the anomaly up-front and how you expect the patient's altered structure to impact the procedure, Rappo says. Include start and stop times for the procedure to substantiate that the tap took longer than a normal puncture.

When performing a spinal tap on a premature infant or baby, you may consider modifier -63 (Procedure performed on infant less than 4 kg). "Premies and small babies have the potential to make procedures even more difficult," Rappo says. To compensate physicians for this increased risk and work, CPT created modifier -63.