ED Coding and Reimbursement Alert

Question: During a lumbar puncture, the patient's left leg became numb, and he had severe paresthesias. The ED physician stopped the procedure before he had  retrieved cerebrospinal fluid. How should we code this?

Indiana Subscriber
 
Answer: You should report the lumbar puncture as 62270 (Spinal puncture, lumbar, diagnostic) with modifier -53 (Discontinued procedure) appended.

Modifier -53 describes a procedure discontinued "due to circumstances that threaten the well-being of the patient," according to CPT.

Warning: You cannot code this modifier if you stop only because of physician inconvenience. Many groups have elected not to bill for painful, unsuccessful procedures that were not completed, particularly if the patient had an adverse event.